Central nervous system infections in Filipino patients with systemic lupus erythematosus

Abstract

Background and purpose: Infections including those of the central nervous system (CNS) are a major contributor to morbidity and mortality in systemic lupus erythematosus (SLE). This case series describes the etiology, contributing factors and outcomes of CNS infections in a group of Filipino patients with SLE.

Design: Retrospective case series.

Methods: We reviewed the medical records of SLE patients diagnosed and confined for a CNS infection at the University of Santo Tomas Hospital in Manila, Philippines, from 1997 to 2007.

Results: A total of 23 SLE patients (22 females) diagnosed with CNS infection were included in this study. The mean age was 25.8 years (range 12-51) at SLE diagnosis, and 30.9 years (range 14-58) at CNS infection, with a mean disease duration of 55 months (range 7-125). Nineteen cases (82.6%) were meningitis, and four (17.4%) were diagnoses of brain abscess. The etiologic agents were identified as Cryptococcus neoformans in seven (30.4%), Mycobacterium tuberculosis in seven (30.4%), Streptococcus pneumoniae in two (8.7%), Salmonella sp. in one (4.4%), Corynebacterium bovis with Actinomyces sp. in one (4.4%), and no isolate in five (21.7%). The average daily prednisone dose was 28.9 mg (range 0-60 mg); 10 patients had recently received pulse cyclophosphamide, and two were on mycophenolate mofetil at the time of infection. Most cases had active SLE; the lone patient in disease remission had S. pneumoniae meningitis post-splenectomy. The most common presentation was headache (100%) and fever (87%). The infection resolved completely in nine patients (39.1%), and resolved with sequelae in two patients (8.7%); 12 patients (52.2%) died.

Conclusion: We described the etiology and outcomes of CNS infections in a group of Filipino patients with SLE. Risk factors included active SLE in the majority of cases requiring moderate- to high-dose steroids and other immunosuppressants like cyclophosphamide. Although C. neoformans and M. tuberculosis were the most common etiologic agents, it is just as important to search for less common organisms which can produce disease in highly susceptible hosts. A high index of suspicion and early appropriate management are crucial to favorable outcome among these patients.