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

Core Tip: Infection is a common complication of systemic lupus erythematosus (SLE) treated with glucocorticoids and immunosuppressants, but multiple cerebral abscesses caused by a rare pathogen are uncommon. Conventional treatment includes surgery and antibiotics. However, due to concerns about SLE exacerbation after the reduction of glucocorticoid and immunosuppressant, and poor tolerability to surgery for multiple cerebral abscesses in patients with SLE, treatment is often difficult, and selection of antibiotics sensitive to rare pathogens is challenging. We report a patient who benefited from individualized surgical treatment of multiple cerebral abscesses, and a multi-antibiotic regimen, with good outcomes.