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Am J Psychiatry 139:12, December 1982 CLINICAL AND RESEARCH REPORTS 1631

ECT for Depression Caused by Lupus Cerebritis: A Case Report


admitted to the renal unit for fever, alopecia, arthralgias,

The authors describe the case ofa 33-year-old woman who
erythema nodosum, malar rash, and glomerulonephritis with
had an organic affective syndrome associated with docu-
active lupus serologies. Subsequently, while her steroid dose
mented lupus cerebritis. The organic affective disorder did
was being tapered rapidly, she developed bizarre and with-
not respond to high-dose intravenous steroids but subse-
drawn behavior, paranoid delusions, and command auditory
quentlv responded to electroconvulsive therapy (Am J Psy- .
hallucinations. A lumbar puncture was normal except for a
chiatry 139:1631-1632, 1982)
slightly low glucose level. Ms. A’s steroid dose was in-
creased to its previous level, and she was transferred to the
A variety of psychiatric disorders occur in patients psychiatric service. Her symptoms resolved and did not
with systemic lupus erythematosus (1-7). These disor- recur with a more gradual tapering of the steroid dose. Of
note, Ms. A had had a similar psychotic depression 12 years
ders may be caused by the underlying organic condi-
previously, after a stillbirth; the depression resolved without
tion, by a reaction to the illness, by the steroid
treatment after 6 months and did not recur with the birth of
treatment, or by a combination of these three factors. her two children. She had no family history of psychiatric
Clinically, it is often difficult to determine which illness.
factors are predominantly contributing to the psychiat- At the time of this admission, physical examination was
nc problems at any one time, and the appropriate unremarkable. Routine hematologic and biochemical studies
method of treatment may accordingly be difficult to were normal with the exception of a mild microcytic anemia
determine. In this paper, we report on a woman with and elevated sedimentation rate (55 mm/hour).
well-documented systemic lupus erythematosus who Ms. A continued to receive maintenance steroid treatment
developed a life-threatening affective syndrome in the and was observed without being given psychotropic medica-
tions. On hospital day 4, she attempted suicide by slashing
absence of other clinical manifestations of lupus ery-
her wrists and neck and admitted to command auditory
thematosus but whose laboratory findings strongly
hallucinations. She was started on treatment with imipra-
suggested an underlying cerebritis. Most interesting,
mine, 200 mg/day, and trifluoperazine, 45 mg/day, but re-
her organically based psychiatric disorder did not mained severely depressed, delusional, and suicidal. Serolo-
respond to high doses of steroids or to psychotropics gies indicated active lupus. Lumbar puncture revealed CSF
but improved dramatically with ECT. pleocytosis (12 leukocyte/p.l, 92% lymphocytes, 5% neutro-
phils, 3% monocytes), 44 mg/dl of glucose, and 56 mg/dl of
Case Report
protein. She was given high-dose intravenous steroid treat-
Ms. A, a 33-year-old secretary, was admitted to our ment for her lupus cerebritis on day 10. At this time she was
psychiatric service with a 2-month history of depressed mute with waxy flexibility and negativism and all psychotro-
mood, irritability, social withdrawal, delusions of reference, pic medications were stopped. After her presumed neurolep-
and guilty ruminations. Vegetative symptoms included a 2- tic-induced catatonia cleared, she demonstrated disorienta-
week history ofdecreased appetite, a 2-kg weight loss, early tion to date; marked deficits
in attention, concentration, and
and terminal insomnia, and an inability to concentrate. calculations; and impaired recent memory with confabula-
Formal testing of cognitive functions revealed no evidence tion and perseveration. She received intravenous methyl-
of an organic mental syndrome at this time. Her medical prednisolone, 60-80 mg/day, for 4 weeks, and during this
status had been stable during the preceding 6 months, during time her psychiatric symptoms waxed and waned. Each
which she had taken 20 mg of prednisone every other day. attempt to decrease the dose of methylprednisolone below
Lupus serologies 6 weeks before admission showed 2+ 60 mg/day was associated with an increase in her confusion
antinuclear antibodies and normal Farr and complement and agitation. Because her severe organically based affective
studies. disorder had not responded to psychotropic drugs or to
Ms. A had had one previous psychiatric hospitalization, a steroid treatment, she was given electroconvulsive therapy
year before this admission, which coincided with the docu- (ECT).
mented onset of her lupus erythematosus. She had been Ms. A received 1 1 bilateral ECT sessions (160 V for .75
sec) over the next month and had a gradual and complete
resolution of sleep and appetite disturbances, paranoid and
Received May 24, 1982; revised July 22, 1982: accepted July 28,
somatic delusions, auditory hallucinations, suicidal ideation,
1982. From the Payne Whitney Psychiatric Clinic, the New York and, ultimately, cognitive deficits. Her steroid dose was
Hospital-Cornell Medical Center. Address reprint requests to Dr. slowly tapered during her course of ECT, and she was
Douglas, Payne Whitney Psychiatric Clinic, the New York Hospital- discharged with a maintenance prednisone dose of5 mg/day.
Cornell Medical Center, 525 East 68th St., New York, NY 10021.
The authors thank Allen Frances, M.D. , Samuel Perry, M.D. , and
Margaret Gilmore, M.D. , for assistance in the preparation of the
Copyright 1982 American Psychiatric Association 0002-953X/82/ The successful use of ECT in this case suggests that
12/163 1/02/$00.50. this modality is an effective treatment for affective
1632 CLINICAL AND RESEARCH REPORTS Am J Psychiatry 139:12, December /982

disorders associated with lupus cerebritis. Allen and thors, e.g., Dudley and Williams (10), have reported
Pitts (8) described two patients with lupus who had its efficacy for various conditions.
unipolar depression that was successfully treated with We decided to use ECT in this case because of the
ECT. Guze (1) reported on three patients with lupus severity of the patient’s psychotic depression and
and associated organic brain syndrome, affective dis- persistent suicidal intent and because she failed to
order, and schizophreniform psychosis who respond- respond to a briefcourse ofpsychotropic medications.
ed to ECT. However, neither report mentioned CSF We recommend that ECT be considered for lupus
abnormalities suggestive of lupus cerebritis. Without patients with affective syndromes which fail to resolve
this and other historical data, it is not clear if these with conventional high-dose steroid therapy and psy-
patients were suffering from lupus cerebritis, a steroid chotropic medications or which require more immedi-
reaction, or an independent affective syndrome, and ate intervention than such medication affords.
thus it is difficult to interpret the patients’ response to
It is possible that our patient had a major depressive 1. Guze SB: The occurrence of psychiatric illness in systemic
disorder concurrent with systemic lupus erythemato- lupus erythematosus. Am J Psychiatry 123: 1562-1570, 1967
sus. Although we have no definitive diagnostic mea- 2. Bennett R, Hughes GR, Bywaters EG, et al: Neuropsychiatric
problems in systemic lupus erythematosus. Br Med J 4:342-345.
sures for such cases, several factors lead us to think
otherwise. Although her depression developed before 3. MacNeill A, Grennan DM. Ward D. et al: Psychiatric problems
the appearance of organic signs, her sedimentation in systemic lupus erythematosus. Br J Psychiatry 128:442-445.
rate was high when she was admitted and lupus 1976
4. Sergent JS, Lockshin MD. Klempner MW. et al: Central
serologies were positive, indicating the presence of nervous system disease in systemic lupus erythematosus. Am J
active lupus. The presence of an abnormal CSF, the Med 58:644-645, 1975
persistence ofdepressive and organic signs in tandem, 5. Clark EC. Bailey AA: Neurological and psychiatric signs asso-
ciated with systemic lupus erythematosus. JAMA 160:455-457,
and, especially, their remission together after ECT
lead us to believe that this was a case of an organic 6. Feinglass EJ, Arnett FC, Dorsch CA, et al: Neuropsychiatric
affective syndrome associated with lupus cer- manifestations of systemic lupus erythematosus: diagnosis.
ebritis. clinical spectrum and relationship to other features of the
disease. Medicine (Baltimore) 55:323-339, 1976
It should be noted that the patient’s response may
7. Kassan 55, Lockshin MD: Central nervous system lupus ery-
have been related to the nonspecific efficacy of ECT in thematosus. Arthritis Rheum 22: 1382-1385. 1979
a variety of acute organic brain disorders rather than 8. Allen RE, Pitts FN Jr: ECT for depressed patients with lupus
to the specific underlying organic etiology (lupus cere- erythematosus. Am J Psychiatry 135:367-368, 1978
9. Kramp P, Bolwig TG: Electroconvulsive therapy in acute
britis) or to the clinical features of her psychiatric delirious states. Compr Psychiatry 22:368-371. 1981
syndrome. Although the use of ECT for organic brain 10. Dudley WH, Williams JG: Electroconvulsive therapy in deliri-
disorders remains controversial (9), a number of au- urn tremens. Compr Psychiatry 13:357-360, 1972