Effectiveness of olanzapine for systemic lupus erythematosus-related psychosis.

Sir: We report a case of olanzapine treatment of psychotic symptoms related to systemic lupus erythematosus (SLE). There is evidence that SLE can affect the central nervous system, among other parts of the body. Reports of psychotic presentation in SLE are rare, but such presentations are often dramatic, causing impairment in quality of life and difficulties for treatment.1,2 To our knowledge, there are no reports of effectiveness of olanzapine, an atypical antipsychotic, for SLE-related psychosis. Case report. Ms. A, a 14-year-old adolescent girl, was diagnosed with SLE in 2002 at age 10, when she presented with high fever, polyarthritis, purpura, systemic arterial hypertension, and laboratory abnormalities (lymphopenia and positive antinuclear and native DNA antibodies). She fulfilled the American College of Rheumatology diagnostic criteria3 for SLE. At the time she was originally diagnosed, she received therapy with methylprednisolone (pulse therapy) for 6 months, followed by azathioprine (50 mg/day) for 2 years. Later, in 2004, she was followed in a pediatric out-patient clinic and treated with prednisone (20 mg/day) and hydroxychloroquine (400 mg/day), which she continued throughout follow-up. At age 14, she was admitted to an inpatient unit presenting with progressive agitation, persecutory and auto-reference delusions, visual and auditory hallucinations with command voices that encouraged her to commit suicide (2 attempts to self-harm), soliloquies, and insomnia. Symptom onset was rapid and became apparent 10 days prior to admission. Her rheumatologist concluded that she had not had a new SLE crisis, since SLE markers were not different from previous exams, and that the psychotic symptoms were not caused by medication adjustment. The findings of her brain computed tomography (CT) and serologic exams (HIV and syphilis) and biochemical examination results were all within normal limits. She had no family history of psychiatric disorders. She was administered haloperidol 5 mg/day with minimum improvement and significant extrapy-ramidal side effects. That medication was stopped, and olanzapine 5 mg/day was initiated and was increased to 7.5 mg/day within 15 days. She became symptom free within 15 days of olanzapine initiation and remained so for 4 months. The dose was then decreased to 5 mg/day due to weight gain (5 kg), and the patient remains symptom free to date. This patient had a 4-year history of SLE with multiple complications, including her psychotic outbreak. She had been taking corticosteroids since her diagnosis and had no dose alteration in the last 2 years before her psychiatric manifestation. Since she had no family history of psychosis or changes in her SLE treatment, this case is not likely to be a first episode or a medication-induced psychosis. Moreover, diffuse brain disease in SLE can be difficult to assess because of its sparse biological expression, usually resulting in normal neuroimaging and laboratory findings.4 Thus, it is likely that psychiatric presentation in SLE patients should be considered as SLE induced. The usual treatment of SLE-related psychosis involves immunosuppressant and/or antipsychotic therapy.5 Regarding atypical antipsychotics, as far as we know, only risperidone, alone or in combination with valproic acid, has been used.6–8 On the other hand, there are reports of antipsychotic-induced lupus with traditional (chlorpromazine9,10) and atypical (clozapine11,12 and ziprasidone13) agents. Successful treatment of SLE-related psychosis with olanza-pine brings another therapeutic option to those patients, although controlled studies would be necessary to further confirm this observation.