OA19 Acute confusion, reduced conscious levels and stroke in systemic lupus erythematosus resulting from cerebral vasculitis

Abstract Introduction Systemic lupus erythematosus (SLE) presents substantial challenges, particularly in cases of major organ involvement, particularly within the central nervous system, which may be characterised by acute neurological symptoms including seizures and altered levels of consciousness. These cases often necessitate careful consideration of potential alternate causes, particularly infection. Brain imaging can often be normal in neurological manifestations of the disease but a wide array of abnormalities have previously been reported on scans. This case underscores the challenges clinicians face in managing complex lupus with severe neurological manifestations, emphasizing the critical importance of promptly recognizing serious symptoms and initiating effective definitive treatment. Case description A 20-year-old woman with SLE presented to hospital having been diagnosed with the disease nine months earlier whilst living in the Caribbean. Diagnosis was based on a malar rash, inflammatory arthritis, and peripheral oedema with an active urinary sediment for which she was presumed to have lupus nephritis (LN). She gave a history of one previous episode of generalised tonic clonic seizure, for which she was treated with levetiracetam. At that time, the underlying aetiology of her seizure was unclear. Initial management was with a combination of prednisolone and azathioprine. Upon arrival in the UK, she was hospitalized with worsening peripheral oedema, hypoalbuminemia, and acute kidney injury. A renal biopsy subsequently confirmed mixed Class IV / V LN with active and chronic lesions. In turn she was treated with high-dose glucocorticoids and Azathioprine was switched to Mycophenolate. Despite treatment, her renal function deteriorated to established CKD stage 4. Shortly after discharge, she presented acutely unwell with diarrhoea, vomiting, hyperkalaemia, an acute on chronic kidney injury and fluid overload. She very acutely dropped her GCS with a CT head showing changes in the left frontal lobe, and an MRI revealed numerous ill-defined lesions suggesting a multiphasic inflammatory process. Despite treatment for possible CNS infection, her condition deteriorated, requiring ICU admission for ventilatory and renal support. There was uncertainty surrounding brain imaging which further complicated decisions regarding treatment plan. CSF samples and a negative infection screen excluded infections. Initial scans suggested multifocal infarctions, which