Neuropsychiatric Symptoms as the First Manifestation of Systemic Lupus Erythematosus in an Older Adult: A Case Report

Case Description: A 68-year-old man with subacute symptoms of irritability, abulia, anhedonia, apathy, anorexia, and weight loss. Clinical Findings: He had erythematous-violaceous plaques on the face, trunk and arms; poikiloderma in lower limbs, livedo reticularis, clubbing and melanomichia. On mental examination he presented apathetic and indifferent with a flat affect. Pancytopenia and intrahepatic cholestasis were documented. Infectious, nutritional and infiltrative causes were ruled out, as well as malignancy or structural alterations in the liver or central nervous system that could explain the symptoms. Treatment and Outcome: Autoimmunity studies together with skin biopsy led to the diagnosis of systemic lupus erythematosus (SLE). Given the initial suspicion of confusional syndrome versus depression with psychotic symptoms, he received sequential management with multiple antipsychotics; the start of the systemic steroid led to resolution of symptoms. Clinical Relevance: SLE mainly affects young women; in older adults it is uncommon and underlying malignancy must always be ruled out. Neuropsychiatric manifestations are atypical in this group, with cognitive impairment and behavioral disorders observed in 1-5% of cases. (1) It is important to consider it as a differential diagnosis in patients with symptoms refractory to conventional management, giving that there may be improvement with immunomodulatory treatment.