SEIZURES SECONDARY TO FUNGAL NEUROINFECTION DUE TO CYCLOPHOSPHAMIDE IN LUPUS PATIENT - A CASE REPORT

SEIZURES SECONDARY TO FUNGAL NEUROINFECTION DUE TO CYCLOPHOSPHAMIDE IN LUPUS PATIENT - A CASE REPORT

CANAAN, JOÃO PAULO; VICO, LAÍS DE; LANÇAS, SEAN HIDEO SHIRATA; BRUFATTO, MATHEUS ZANATA; TOLEDO, JOELY CRISTINA DA SILVA; OLIVEIRA, LÍVIA CÂMARA; PACHECO, SULA GLAUCIA LAGE DRUMOND; BATISTA, ANDREA DE ALMEIDA PEDUTI; VALENTE, LUIZ EDUARDO; SAMPAIO, HENRIQUE PEREIRA; LEITE, FABIO VICENTE

Pôster:

Systemic Lupus Erythematosus (SLE) is an autoimmune disease, with recurrent clinical flares, characterized by immune tolerance loss to various autoantigens, associated to immune complexes deposits that generates inflammation of different organs and systems. To control the inflammatory activity of the disease, it’s necessary the use of immunosuppressive drugs, often causing susceptibility to infections.

Case report

R.E.S.P, 45, with SLE, morbid obesity, systemic hypertension, hypothyroidism, depressive and anxiety disorders, underwent to renal biopsy because of corticosteroid refractory proteinuria of 1.380 mg/24 h. Class IV lupus nephritis was identified. It was followed by induction with Methylprednisolone plus Cyclophosphamide 0.75 g/m² monthly for 6 months and maintenance with Azathioprine, after achieving complete remission in 2017 December. Two months later she was admitted to investigate headache and seizures. Brain Tomography suggested Toxoplasmosis infection, not confirmed by serologic acute phase research (lumbar puncture not performed due to midline deviation). Was started then empiric treatment with Sulfamethoxazole plus Trimethoprim, Dexamethasone and Anticonvulsants and performed a brain MRI, disagreeing from the Tomographic diagnosis. So a cerebral biopsy was performed excluding neoplasia, toxoplasma and confirming the presence of Candida spp. The treatment with Liposomal Amphotericin B had a good response.

Conclusion

Cyclophosphamide is used to treat severe SLE and other autoimmune disorders. There are rare potential toxic effects, such as hematological, renal, gonadal, embryonic, cardiac and vesical. However the main ones are those related to immunosuppression, predisposing the patients sometimes to emergency infections caused mainly by viruses and bacteria and more rarely by opportunistic agents such as fungi, (including Candida spp.), Pneumocystis jirovecii and Cryptococcus neoformans. The current Case Report exemplifies an opportunistic fungal neuroinfection by Candida spp. predisposed by Cyclophosphamide and demonstrating the importance of monitoring those patients.

Systemic Lupus Erythematosus (SLE) is an autoimmune disease, with recurrent clinical flares, characterized by immune tolerance loss to various autoantigens, associated to immune complexes deposits that generates inflammation of different organs and systems. To control the inflammatory activity of the disease, it’s necessary the use of immunosuppressive drugs, often causing susceptibility to infections.

Case report

R.E.S.P, 45, with SLE, morbid obesity, systemic hypertension, hypothyroidism, depressive and anxiety disorders, underwent to renal biopsy because of corticosteroid refractory proteinuria of 1.380 mg/24 h. Class IV lupus nephritis was identified. It was followed by induction with Methylprednisolone plus Cyclophosphamide 0.75 g/m² monthly for 6 months and maintenance with Azathioprine, after achieving complete remission in 2017 December. Two months later she was admitted to investigate headache and seizures. Brain Tomography suggested Toxoplasmosis infection, not confirmed by serologic acute phase research (lumbar puncture not performed due to midline deviation). Was started then empiric treatment with Sulfamethoxazole plus Trimethoprim, Dexamethasone and Anticonvulsants and performed a brain MRI, disagreeing from the Tomographic diagnosis. So a cerebral biopsy was performed excluding neoplasia, toxoplasma and confirming the presence of Candida spp. The treatment with Liposomal Amphotericin B had a good response.

Conclusion

Cyclophosphamide is used to treat severe SLE and other autoimmune disorders. There are rare potential toxic effects, such as hematological, renal, gonadal, embryonic, cardiac and vesical. However the main ones are those related to immunosuppression, predisposing the patients sometimes to emergency infections caused mainly by viruses and bacteria and more rarely by opportunistic agents such as fungi, (including Candida spp.), Pneumocystis jirovecii and Cryptococcus neoformans. The current Case Report exemplifies an opportunistic fungal neuroinfection by Candida spp. predisposed by Cyclophosphamide and demonstrating the importance of monitoring those patients.

Palavras-chave:

DOI: 10.5151/sbr2019-238

Referências bibliográficas

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Como citar:

CANAAN, JOÃO PAULO; VICO, LAÍS DE; LANÇAS, SEAN HIDEO SHIRATA; BRUFATTO, MATHEUS ZANATA; TOLEDO, JOELY CRISTINA DA SILVA; OLIVEIRA, LÍVIA CÂMARA; PACHECO, SULA GLAUCIA LAGE DRUMOND; BATISTA, ANDREA DE ALMEIDA PEDUTI; VALENTE, LUIZ EDUARDO; SAMPAIO, HENRIQUE PEREIRA; LEITE, FABIO VICENTE; "SEIZURES SECONDARY TO FUNGAL NEUROINFECTION DUE TO CYCLOPHOSPHAMIDE IN LUPUS PATIENT - A CASE REPORT", p-238-238. In: Anais do 36º Congresso Brasileiro de Reumatologia. [ISBN 978-85-212-1892-0]. São Paulo: Blucher, 2019.
ISSN 23577282, DOI 10.5151/sbr2019-238