Diffuse leukoencephalopathy and subacute parkinsonism as an early manifestation of systemic lupus erythematosus

Abstract

Parkinsonism in SLE is rare. Diffuse leukoencephalopathy is equally uncommon and is associated with a poor prognosis. We present a single case of a 50-year-old Filipino man who presented with a generalized discoid rash after starting lisinopril. The rash persisted despite discontinuation of lisinopril, and over the next three months, he developed rapidly progressive parkinsonism. Brain MRI showed symmetric confluent T2-hyperintensities involving the white matter and basal ganglia. Four of the 11 American College of Rheumatology criteria for the classification of SLE were met. A rheumatologist made a diagnosis of SLE with cutaneous and central nervous system involvement. Significant neurologic and radiologic improvement occurred following treatment with IV steroids followed by a prolonged taper. This report highlights a case of subacute parkinsonism with a diffuse leukoencephalopathy as an early manifestation of SLE which resulted in a good recovery following treatment with only immunosuppressive therapy.

Figure 1

50-year-old male presenting with diffuse, confluent leukoencephalopathy and subacute parkinsonism. Axial brain MRI FLAIR sequence on initial presentation showing extensive confluent symmetric hyperintensities ((a) and (b)). Gross skin punch biopsy from right knee (c) shows superficial ((d), arrows) and deep perivascular dermatitis ((e), arrows) with focally increased dermal mucin highlighted by Alcian blue stain (f). Repeat axial brain MRI FLAIR sequence after 5 months demonstrating radiographic improvement following immunosuppressive therapy ((g) and (h)).