Systemic lupus erythematosus with disseminated aspergillosis misdiagnosed as lupus encephalopathy: a case report and literature review

BACKGROUND: Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease. Patients with SLE presenting sudden vision lost with intracranial and intrathoracic space-occupying lesions are distinctly rare clinically. People may be simply consider this multiple damages with disease activity. The process of differential diagnosis requires rigour and efficiency in both its thoroughness and efficiency. Because of their immunosuppressive state, patients with SLE are susceptible to infection than general population, which may be misdiagnosed as immune disorder. CASE DESCRIPTION: In this article, we present a case of 40-year-old woman suspected with SLE at 1.5 years ago. In December 2020, this patient experienced with high fever, lupus hepatitis and autoimmune hemolytic anemia and thrombocytopenia, for which she was administered glucocorticoids and rituximab. Her symptoms were relieved and the dosage of prednisolone were gradually reduced to 15 mg per day. In May 2021, she experienced a sudden bilateral loss of vision. Ophthalmic examination showed posterior uveitis intracranial space-occupying lesions. Contrast-enhanced head magnetic resonance imaging (MRI) and chest computed tomography (CT) both showed multiple abnormal foci. According to the past history of SLE, the ophthalmology department of the local hospital misdiagnosed as lupus encephalopathy with uveitis. Unfortunately, the patient’s vision didn’t improve after she received high-dose glucocorticoid therapy. The patient was then transferred to our hospital. We measured her SLEDAI-2k score which was only 0 point. According to the humoral immunity is prevalently low, infectious causes should be considered firstly. We performed lumbar puncture for her, but the next-generation sequencing (NGS) of cerebrospinal fluid did not provide a significant sign for infection. Further, we performed an emergent vitreous tap and finally confirmed by the NGS of the vitreous fluid, that it was a multi-site infection caused by disseminated aspergillosis. Following anti-infective treatment, the patient’s lung and intracranial lesions were absorbed; however, her vision was not restored. CONCLUSIONS: We experienced a rare case of disseminated aspergillosis which was misdiagnosed as lupus encephalopathy. Infectious causes should always be at the top on the list of differential diagnoses when people with SLE accompanying by uveitis or multiple system damage. The bacterial culture of the vitreous fluid may aid in the diagnosis of infectious endophthalmitis.