A 32-year-old woman comes to the office accompanied by her sister. The patient says "my sister thinks I'm losing my mind; I don't know what's going to happen to me." Her sister states that for the past few weeks the patient has become convinced that "ballerinas" are visiting her apartment and going through her belongings. The patient says, "At first I wasn't sure, but now I know they've been coming to scare me out of my apartment. I see them sometimes running around at night. The one with the long black hair wants to strangle me. I'm scared for my life." The patient's sister has not noted any intruders. The patient does not appear to be otherwise confused. In review of systems, she acknowledges feeling more tired over the past few months and losing 4.5 kg (10 lb) over the same period. She also reports pain in her knuckles and wrists. Medical history is unremarkable except for episodes of recurrent depression in her 20s. She takes no medications. The patient does not use tobacco, alcohol, or illicit drugs. She has a family history of depression. Temperature is 36.7 C (98.1 F), blood pressure is 148/92 mm Hg, pulse is 82/min, and respirations are 16/min. Examination shows mildly swollen wrists bilaterally and mild edema in both lower extremities but is otherwise normal. Laboratory results show a white blood cell count of 3,900/mm³; serum chemistries are within normal limits. Which of the following is the most appropriate next step in diagnostic evaluation of this patient?

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Explanation: 11ec2b69_c1b1_fb55_8f63_f3833a714b62_MD0005_00 This patient's signs and symptoms are suggestive of systemic lupus erythematosus (SLE). SLE is an autoimmune disorder that occurs primarily in young women of child-bearing age. It may be characterized by a broad range of symptoms and findings, including, but not limited to, constitutional symptoms (eg, fever, fatigue, weight loss), joint pain and swelling, lower extremity swelling, pericarditis, hypertension, Raynaud phenomenon, malar rash, and neuropsychiatric symptoms. Leukopenia, anemia, and/or thrombocytopenia may also be noted. The diagnosis of SLE can be supported by the presence of antinuclear antibodies (ANA), particularly anti-double stranded DNA and anti-Smith antibodies. If this patient has positive titers for ANA, she would fit criteria for SLE. findings Neuropsychiatric symptoms associated with SLE may include headache, seizures, polyneuropathies, cognitive dysfunction, anxiety, mood changes, and/or new-onset psychosis, the latter occurring in nearly 5% of patients. Psychosis due to SLE may be treated symptomatically with antipsychotics, but symptoms usually respond well to oral steroids within 2-4 weeks. (Choice A) Urinary porphobilinogen is elevated in acute intermittent porphyria, a hereditary disorder characterized by intermittent neurovisceral symptoms that can present with acute psychosis. This patient's lack of acute abdominal pain (the most common symptom) and lack of family history of similar symptoms make this condition unlikely. (Choices B and C) The lack of focal neurological findings or fever/meningismus obviates any immediate need for imaging studies or a lumbar puncture, respectively. However, after the initial step of serological evaluation, brain imaging studies (MRI rather than CT scan) may still be beneficial for the evaluation of central nervous system changes due to SLE. (Choice D) A slit-lamp eye examination can be used to look for copper deposits in the cornea (Kayser-Fleischer rings), a possible sign of Wilson disease, a disorder of copper transport in which copper accumulations cause hepatic, psychiatric, and neurologic dysfunction. Findings include dysarthria, dystonia, tremor, and parkinsonism. none of which are seen in this patient. In addition, although Wilson disease can cause psychosis, depression is a more common psychiatric manifestation. Educational objective: Systemic lupus erythematosus is an autoimmune disorder characterized by a broad range of possible clinical signs and symptoms, including new-onset psychosis. If lupus is suspected, a positive antinuclear antibody test can support the diagnosis. References: Psychiatric symptoms in systemic lupus erythematosus: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/22687742) The diagnosis and clinical management of the neuropsychiatric manifestations of lupus. (http://www.ncbi.nlm.nih.gov/pubmed/27427403)

A 32-Year-Old Woman Comes to the Office Accompanied by Her