Surgery and antibiotics for the treatment of lupus nephritis with cerebral abscesses: A case report

Abstract

Background: Systemic lupus erythematosus (SLE) patients are extremely susceptible to opportunistic infections due to glucocorticoid and immunosuppressive treatments, which often occur in the respiratory system, the urinary system and the skin. However, multiple cerebral infections are rarely reported and their treatment is not standardized, especially when induced by a rare pathogen.

Case summary: A 46-year-old woman was treated with glucocorticoid and immunosuppressant for SLE involving the hematologic system and kidneys (class IV-G lupus nephritis) for more than one year. She was admitted to hospital due to headache and fever, and was diagnosed with multiple cerebral abscesses. Brain enhanced magnetic resonance imaging showed multiple nodular abnormal signals in both frontal lobes, left parietal and temporal lobes, left masseteric space (left temporalis and masseter region). The initial surgical plan was only to remove the large abscesses in the left parietal lobe and right frontal lobe. After surgery, based on the drug susceptibility test results (a rare pathogen Nocardia asteroides was found) and taking into consideration the patient's renal dysfunction, a multi-antibiotic regimen was selected for the treatment. The immunosuppressant mycophenolate mofetil was discontinued on admission and the dose of prednisone was reduced from 20 mg/d to 10 mg/d. Re-examination at 3 mo post-surgery showed that the intracranial lesions were reduced, the edema around the lesions was absorbed and dissipated, and her neurological symptoms had disappeared. The patient had no headaches or other neurological symptoms and lupus nephritis was stable during the 2-year follow-up period.

Conclusion: In this report, we provide reasonable indications for immunosuppression, anti-infective therapy and individualized surgery for an SLE patient complicated with multiple cerebral abscesses caused by a rare pathogen, which may help improve the diagnosis and treatment of similar cases.

Keywords: Case report; Multi-antibiotic therapy; Multiple cerebral abscesses; Nocardia asteroides; Systemic lupus erythematosus.

Figure 1

Brain magnetic resonance imaging of the patient. A-C: Sequential MR-T2WI of both frontal lobes, left parietal lobe, and left masseteric space. Images show multiple nodular lesions with significant perilesional edema; D-F: Sequential MR-DWI show high level of lesion signal change; G-I: Sequential enhanced MR-T1WI showing low lesion signals that are slightly higher than the cerebrospinal fluid signal, and uniform, intact and round annular enhancement around the lesions.

Figure 2

Surgical strategy. A: Orange arrow indicates the left maxillofacial lesion on which puncture aspiration was performed; B and C: Red arrow indicates the smaller non-resected lesions located in the deeper parts of the left frontal and temporal lobes; Green arrows indicate the larger lesions with greater perilesional edema in the right frontal lobe and left parietal lobe which were resected.

Figure 3

Preoperative and postoperative brain magnetic resonance imaging. A-C: Sequential preoperative enhanced MR-T1WI showing low lesion signals that are slightly higher than cerebrospinal fluid signal, and uniform, intact and round annular enhancement around the lesions. There are also low perilesional edema signals that are slightly higher than the cerebrospinal fluid signal; D-F: Sequential MR-T1WI at 1 mo post-surgery showing absence of the resected lesions in the right frontal lobe and left parietal lobe, and formation of soft lesions. Lesion in the left maxillofacial region on which puncture aspiration was performed was also absent. Non-resected lesions in the left frontal and temporal lobes were reduced in size, and low edema signals can be observed around the lesions in the left temporal lobe; G-I: Sequential MR-T1WI at three months post-surgery showing further reduction in the size of non-resected lesions in the left frontal and temporal lobes compared with those at 1 mo post-surgery. Edema was absorbed and dissipated.

Figure 4

Systemic lupus erythematosus related indicators were followed up for 2 years after discharge. A: Changes in routine blood levels 1; B: Changes in routine blood levels 2; C: Changes in liver function; D and E: Changes in renal function; F: Changes in C3, C4.