(343) From Schizophrenia to Lupus: How Social Determinants of Health Impacted a Patient’s Clinical Course

Introduction: Systemic lupus erythematosus (SLE) is a common autoimmune condition, with higher prevalence among minorities and individuals with low socioeconomic status. Neuropsychiatric manifestations (NPSLE) can be the presenting symptom of SLE and as such can lead to misdiagnosis as a psychiatric disorder.

Description: A 17-year-old female with history of schizophrenia and extensive social history including behavioral disorder, neglect, and foster care placement presented to the pediatric intensive care unit (PICU) with fluid-refractory shock. She was noted to be tachycardic, febrile, and hypotensive requiring a norepinephrine infusion and initiation of broad-spectrum antibiotics. Despite improved hemodynamics with volume resuscitation, her tachycardia and fever persisted for days. She also had waxing and waning mental status with intermittent severe agitation that was initially attributed to her psychiatric disease with no caregiver to confirm. She developed progressive pancytopenia and an elevated CRP with negative blood cultures. Further work up revealed a splenic infarct on CT imaging and significantly elevated ferritin and transaminases concerning for an autoimmune process with macrophage activation syndrome. On hospital day 10, she developed seizure activity and required intubation, prompting a brain MRI that revealed diffuse increased sulcal hyperintensity with increase FLAIR hyperintensity within the cerebellum with prominent leptomeningeal vessels concerning for autoimmune encephalitis. Her antibody panel resulted positive for SSA, SSB, Smith, RNP, and anti-double stranded DNA antibodies confirming NPSLE. Rheumatology recommended initiation of high dose methylprednisolone and anakinra. She was ultimately transitioned to prednisone, mycophenolate, and hydroxychloroquine as her clinical exam and inflammation improved. She was extubated on day 2 of treatment and transferred out of the PICU on day 5.

Discussion: Our patient’s social history produced significant barriers to receiving medical care, which likely contributed to her severity of presentation by the time of her final diagnosis of NPSLE. This case highlights the importance of considering how social determinants of health factor into a patient’s prior diagnoses, current clinical picture, and our own anchoring biases as providers.