Navigating the Challenges of Managing Lupus Cerebritis in the Intensive Care Setting

Introduction: Systemic lupus erythematosus (SLE) is a complex disease with potential for severe multisystem complications. Many SLE patients are admitted to the hospital but rarely are they upgraded to intensive care units for life threatening complications. SLE in the ICU creates unique challenges for intensivists due to risk for hemorrhage, pulmonary complications, and brain hemorrhage.


Description: The patient is a 47-year-old female with past medical history notable only for SLE and CNS Lupus was admitted to the hospital for status epilepticus. She was treated with IV antiepileptics for her seizure and IV glucocorticoids for her SLE. In spite of treatment, the patient continued to develop worsening encephalopathy and increased seizure frequency. The patient was then admitted to the neurocritical care unit for further workup and monitoring. A Lumbar puncture was completed that showed varicella zoster infection. The patient was then started on IV Acyclovir. An MRI of the Brain was also obtained that showed intracerebral and cerebellar vasogenic edema compatible with lupus cerebritis. There was also a new parenchymal hemorrhage noted in the temporal lobe. Around this same time period, the patient developed worsening respiratory distress. A CTA was obtained that noted pulmonary embolism in the segmental pulmonary arteries. Therapeutic anticoagulation was deferred due to ongoing cerebral hemorrhage. In her last days of admission, the patient developed profound hypotension requiring initiation of vasopressors. She also became unresponsive after developing a cardiac arrest. Despite multiple rounds of compressions and epinephrine administration, the patient could not be resuscitated and passed away after 12 days of admission.


Discussion: This case highlights the unique challenges associated with managing SLE and lupus cerebritis in the critical care setting, especially with regards to hematologic management. The patient ultimately expired due to a pulmonary embolism that could not be therapeutically coagulated due to ongoing parenchymal hemorrhage and thrombocytopenia. Furthermore, we emphasize the need for active collaboration between intensivists and other specialists to navigate the multisystem complications of SLE.