Lupus psychosis and attribution in NPSLE (MEQ)

(i) Syndromes and attribution. ACR psychiatric-relevant CNS syndromes include psychosis, mood disorder, anxiety disorder, cognitive dysfunction, and acute confusional state among the broader 19 NP case definitions. This presentation maps to psychosis (with possible mixed mood features). Attribution to SLE is supported by known SLE, serologic activity (low C3, proteinuria), subacute tempo, and multi-system clues — but is not automatic. Exclude infection, substance use, primary psychotic disorder, steroid toxicity (if doses recently escalated), metabolic encephalopathy, and APS-related processes. Depot-only primary schizophrenia framing is premature.[1][2][3]

(ii) Investigations. Joint rheumatology/CL plan: infection screen (cultures, consider LP if meningism/ACS/fever trajectory, opportunistic pathogens as risk warrants), metabolic panel, urine, anti-dsDNA/complements, aPL panel, consider anti-ribosomal P as supportive for diffuse psychiatric NPSLE, MRI brain (may be normal/non-specific), EEG if fluctuating consciousness/seizure risk. Do not treat a normal MRI as exclusion of diffuse NPSLE.[2][3][4]

(iii) Treatment principles. If inflammatory primary NPSLE psychosis is the working attribution after infection exclusion: high-dose glucocorticoids and immunosuppression per EULAR-aligned practice (classically cyclophosphamide for severe inflammatory CNS disease under rheumatology protocol; alternatives if contraindicated/refractory). If aPL/thrombotic phenotype dominates focal vascular disease, prioritise antithrombotic care. Symptomatic: lowest-effective antipsychotic bridge, e.g. olanzapine 2.5–5 mg oral at night with metabolic/QTc monitoring, while disease-modifying therapy proceeds — psychotropics are not definitive cure.[2][3][5]

(iv) Family and capacity. Explain in plain language that immune activity can affect the brain and produce psychosis; tests exclude infection; treatment may include steroids/immunosuppression plus short-term psychiatric medicine; recovery is often good with early care but needs shared teams. Assess capacity for investigation/treatment; if lacking, use local least-restrictive legal framework for emergency care — state principles, not invented foreign section numbers. Safety plan for suicide/aggression risk.[2][3]