Invasive candida infection as the cause of seizure in a patient with systemic lupus erythematosus: a report of unusual case

Abstract

Background: Neuropsychiatric systemic lupus erythematosus (NPSLE) is a complication of SLE involving the nervous and psychiatric systems with clinical manifestations including seizures, strokes, myelopathy, neuritis, meningitis, and psychosis. Seizures in NPSLE might be caused by intracranial infection, with bacteria as the most common pathogens. This study reported a rare case of seizure in a SLE patient due to invasive Candida infection. Case Presentation: A 26-year-old female presented in the emergency department of Dr. Soetomo Hospital Surabaya, Indonesia with seizure, which she has experienced in the last 2 days prior to hospital admission. She experienced a convulsion that lasted 5-10 minutes followed by loss of consciousness. The patient also complained of severe headaches two days before hospital admission. She was diagnosed with SLE in November 2022 and was currently taking methylprednisolone. Physical examination showed Glasgow Coma Scale (GCS) of E3V4M5, fever, dyspnea, and rough rhonchi on the right lung. Chest X-ray indicated pneumonia, while brain computed tomography (CT) suggested subacute to chronic thromboembolism. The patient was diagnosed with NPSLE due to intracranial infection, and hospital-acquired pneumonia (HAP), and was given Levofloxacin. On the 3rd day, a reddish lesion with central healing was found on the cheeks, and the patient had dyspnea, suggesting fungi infection. Methylprednisolone was stopped while fluconazole and urine cultures were initiated. Urine culture suggested Fluconazole-sensitive Candida and consultation with a dermato-venerologist confirmed Candida, thus, Fluconazole was continued along with dexamethasone, and Levofloxacin. The patient showed clinical improvement and was discharged after 12 days. Conclusion: Seizure is one of the most common manifestations of NPSLE, due to intracranial infection. Although rare, we cannot rule out the possibility of fungal infection in NPSLE patients with intracranial infection. Early diagnosis and prompt treatment are critical for better prognosis, as shown in this patient.