A 32-year-old woman is brought to the emergency department by her husband after having an episode of generalized tonic-clonic seizure 30 minutes ago. The patient was watching television when she suddenly started convulsing. The seizure stopped spontaneously after a minute, but she has been lethargic and confused since then. She has no prior history of seizures. According to her husband, the patient has had headaches, fatigue, and irritability for the past 2-3 weeks. She has also had several episodes of pain in her hand joints and wrists, which she attributed to an increased workload as a restaurant chef. The patient has no significant medical history, recent travel, or sick contacts. The only medication she takes is an oral contraceptive. Temperature is 38.1 C (100.5 F), blood pressure is 130/80 mm Hg, pulse is 89/min, and respirations are 12/min. The patient is lethargic but follows instructions. She has an erythematous rash involving both cheeks. There is no tongue laceration, but small oral mucosal ulcers are present. The neck is supple, and other signs of meningeal irritation are negative. Neurological examination shows normal muscle strength and deep tendon reflexes. There is mild swelling and tenderness of the hand joints. Laboratory results are as follows: A noncontrast CT scan of the head is unremarkable. Which of the following is the most likely diagnosis for this patient?

Question

A 32-year-old woman is brought to the emergency department by her husband after having an episode of generalized tonic-clonic seizure 30 minutes ago.  The patient was watching television when she suddenly started convulsing.  The seizure stopped spontaneously after a minute, but she has been lethargic and confused since then.  She has no prior history of seizures.  According to her husband, the patient has had headaches, fatigue, and irritability for the past 2-3 weeks.  She has also had several episodes of pain in her hand joints and wrists, which she attributed to an increased workload as a restaurant chef.  The patient has no significant medical history, recent travel, or sick contacts.  The only medication she takes is an oral contraceptive.  Temperature is 38.1 C (100.5 F), blood pressure is 130/80 mm Hg, pulse is 89/min, and respirations are 12/min.  The patient is lethargic but follows instructions.  She has an erythematous rash involving both cheeks.  There is no tongue laceration, but small oral mucosal ulcers are present.  The neck is supple, and other signs of meningeal irritation are negative.  Neurological examination shows normal muscle strength and deep tendon reflexes.  There is mild swelling and tenderness of the hand joints.  Laboratory results are as follows:  A noncontrast CT scan of the head is unremarkable.  Which of the following is the most likely diagnosis for this patient?

Quizplus · Accepted Answer

11ec25c8_d15d_440a_bc81_d5c43bd489ec_MD0003_00 This patient with a generalized tonic-clonic seizure has evidence of multijoint arthritis, facial rash, oral ulcers, and mild pancytopenia, suggesting a diagnosis of systemic lupus erythematosus (SLE). SLE is a multisystem inflammatory disorder that can affect almost any organ. Central nervous system manifestations commonly include vasculitis, thrombotic or thromboembolic disease (eg, antiphospholipid syndrome), seizures, and transverse myelitis. Cerebrospinal fluid findings may be normal or reflect mild inflammation (eg, slight elevation in CSF leukocytes, lymphocytosis). Given the subacute nature of this patient's symptoms, an inflammatory condition such as SLE is more likely than an infectious disease. (Choice A) Cerebral vein thrombosis usually results in a slowly worsening headache. Focal neurologic deficits and seizure can occur. However, a low-grade fever, malar rash, and pancytopenia would be atypical. (Choice B) Disseminated gonococcal infection often manifests with polyarthritis, tenosynovitis, and skin findings (eg, painless pustules). Disseminated gonococcus would not explain this patient's seizures or pancytopenia. (Choice C) Herpes encephalitis typically presents with acute (<1 week) altered mental status or focal neurologic findings. This patient has had symptoms for 2-3 weeks and has joint pain and a malar rash. (Choice D) Hyperthyroidism typically presents with weight loss, heat intolerance, tremor, anxiety, and loose stools. Seizure is not commonly associated with hyperthyroidism. (Choice E) Most adult patients with parvovirus infection are asymptomatic or have flu-like symptoms, although a minority may develop arthritis or aplastic anemia. Mild pancytopenia would be atypical, and seizures are extremely rare. (Choice F) Rheumatoid arthritis can cause symmetric hand arthritis, low-grade fever, anemia, and thrombocytopenia; however, seizures and a face rash are uncommon. Educational objective: Systemic lupus erythematosus is a multisystem inflammatory disease that can present with central nervous system findings such as a generalized tonic-clonic seizure.

A 32-Year-Old Woman Is Brought to the Emergency Department by Her