Rheumatology 2001; 40: 108-109
© 2001 British Society for Rheumatology
Letters to the Editor |
Sunlight-induced recurrent acute confusion as the initial presentation of systemic lupus erythematosus
Department of Rheumatology, Dudley Group of Hospitals, NHS Trust, The Guest Hospital, Tipton Road, Dudley, West Midlands DY1 4SE, UK
SIR, Neuropsychiatric abnormalities are well-established manifestations of systemic lupus erythematosus (SLE) but are only infrequently encountered as the initial presentation. Chorea, tremor, internuclear ophthalmoplegia, acute transverse myelopathy, Guillain–Barré syndrome, intracranial hypertension and hydrocephalus have been described as presenting features [1–7] in isolated cases. We present a case of recurrent sunlight-induced confusion as the presenting feature of SLE. This has not been previously reported.
A 37-yr-old male presented with acute confusion, disorientation to time and place, short-term amnesia and agitation following an outdoor football activity during a sunny summer day. This man had experienced a similar episode under identical circumstances a few weeks earlier but it had resolved spontaneously within a few hours and no medical attention had been sought. Physical examination revealed acrocyanosis, scalp excoriations and a regular tachycardia. Short mental test score was poor at 3/10, but neurological examination was normal. After 24 h in hospital his confusion cleared and behaviour returned to normal. Toxicology screen was negative and serum biochemistry normal. Proteinuria was detected on dipstick analysis. Further investigations revealed an elevated erythrocyte sedimentation rate (99 mm/h), a C-reactive protein of <1 mg/l, high-titre antinuclear antibodies (1/1600, speckled pattern), positive anti-double-stranded DNA antibodies (148 U/ml (normal range 0–35)) and normal serum immunoglobulins. C3 and C4 levels were low at 0.68 g/l (normal range 0.75–1.75) and 0.08 g/l (normal range 0.20–0.65) respectively. Activated partial thromboplastin time was normal and cardiolipin antibodies and lupus anticoagulant were negative. An MRI of the brain was normal. Chest X-ray and ECG findings led to the suspicion of a pericardial effusion, which was confirmed on echocardiography. Creatinine clearance was normal but 24-h protein excretion was high at 1.23 g. Renal biopsy showed changes of lupus nephritis (WHO classification III). A diagnosis of SLE was made, with six of the American College of Rheumatology classification criteria met [8]. The patient improved clinically and serologically after pulsed cyclophosphamide and steroid therapy and remains well on azathioprine and prednisolone, with no further episodes of confusion.
Direct, prolonged exposure to sunlight is a recognized cause of acute exacerbation of SLE [9] and several effects of ultraviolet radiation at the molecular and cellular levels have been proposed to explain this [10, 11]. In this case, exposure to sunlight was followed by acute confusion and led to the first presentation of hitherto undiagnosed SLE. Poisoning or substance abuse are usually suspected when acute confusion occurs in an outdoor setting in young adults [12]. However, other causes of acute confusion should be sought, particularly SLE, if sunlight appears to be a precipitating factor.
Notes
Correspondence to: G. D. Kitas. 
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