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 Table of Contents  
LETTER TO EDITOR
Year : 2022  |  Volume : 17  |  Issue : 1  |  Page : 91-92

Organic anxiety syndrome in a patient of lupus


Department of Clinical Immunology and Rheumatology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission30-Jan-2021
Date of Acceptance04-Jun-2021
Date of Web Publication22-Jan-2022

Correspondence Address:
Prof. Anupam Wakhlu
Department of Clinical Immunology and Rheumatology, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_26_21

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How to cite this article:
Chandwar K, Dogga P, Sahoo RR, Wakhlu A. Organic anxiety syndrome in a patient of lupus. Indian J Rheumatol 2022;17:91-2

How to cite this URL:
Chandwar K, Dogga P, Sahoo RR, Wakhlu A. Organic anxiety syndrome in a patient of lupus. Indian J Rheumatol [serial online] 2022 [cited 2022 Oct 1];17:91-2. Available from: https://www.indianjrheumatol.com/text.asp?2022/17/1/91/336276



Dear Editor,

A 23-year-old right-handed female had a history of frontal headache and symmetrical polyarthritis for the past 2 years, initially controlled with nonsteroidal anti-inflammatory drugs (NSAIDs). She had complained of severe headache, fever, polyarthritis, dry cough, and pleuritic chest pain 1 year before, which were managed elsewhere with antibiotics and NSAIDs. She was admitted 8 months back with altered behavior and an episode of generalized tonic-clonic seizure and was suspected to have a frontal lobe space-occupying lesion on magnetic resonance imaging (MRI) brain. She subsequently continued to have intermittent fever, altered sensorium, and generalized tonic posturing and persistence of altered behavior, partially controlled with some medicines. She was referred with arthritis and now presented with episodes of severe anxiety for the past 2 months.

Examination revealed pallor, anasarca, bilateral pleural effusion, ascites, and a pressure sore over the sacral prominence, generalized weakness (power 3/5 in all four limbs) with rigidity and flexor plantar response.

Investigations revealed anemia, lymphopenia, and thrombocytopenia, elevated ESR with a normal C-reactive protein. Chest X-ray confirmed bilateral pleural effusion, and echocardiography showed normal cardiac function with moderate pulmonary artery hypertension. MRI brain with angiography revealed subacute frontal bleed with multiple lacunar infarcts in bilateral temporal, parietal, and occipital lobe, with age-inappropriate cerebral atrophy [Figure 1] but normal angiographic picture and a normal cerebrospinal fluid examination. Antinuclear antibody by immunofluorescence revealed 4+ homogenous and cytoplasmic dense fine speckled pattern and a positive anti-dsDNA, anti-nucleosome, anti-ribosomal P protein, anti-histone, and anti-RNP antibodies on immunoblot.
Figure 1: Magnetic resonance imaging brain (axial sections) showing a lesion in left frontal lobe abutting frontal horn of lateral ventricle appearing isointense on T1 (a); hyperintense on T2 (b); without midline shift, suggestive of a well-demarcated parenchymal bleed; and multiple acute lacunar infarcts (arrows) in temporal, occipital, and parietal lobes as seen on diffusion-weighted images (c)

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Despite being initiated on 1 mg/kg of prednisolone, she continued to experience repeated severe anxiety attacks, poorly responsive to anxiolytics. Considering active lupus, with multiple acute infarcts but a negative anti-phospholipid profile, a possibility of neuropsychiatric systemic lupus erythematosus (NPSLE) with central nervous system vasculitis was considered and pulse cyclophosphamide was given. A referral from psychiatry and neurology suggested “organic anxiety syndrome.” She was prescribed sertraline. She rapidly responded to treatment with improvement in anxiety and neurologic functions over a matter of days [Figure 2].
Figure 2: Timeline of events

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Anxiety is common in systemic lupus erythematosus with one meta-analysis reported prevalence of 37% among adult lupus patients.[1] A generalized anxiety disorder is more common and is consequent to lack of understanding and fears associated with the disease and its treatment, and probably inefficient coping strategies.[2],[3] Anxiety attributable to lupus activity per se is termed “organic anxiety disorder,” wherein the anxiety originates due to physiological dysregulation from the underlying illness. The amygdala plays a pivotal role in orchestrating the anxiety responses and can be involved in NPSLE, especially in patients with anti-N-methyl-D-aspartate receptor antibody positivity.[4] Besides, mechanistic associations with other autoantibodies, proinflammatory cytokines, and microvasculopathy have also been reported in studies.[5] Our patient had a large hemorrhagic infarct with marked edema involving the left frontal lobe, possibly disinhibiting the amygdala and precipitating the anxiety disorder. Drugs restoring monoaminergic neurotransmitter dysregulation are effective in controlling anxiety attacks, similar to our case.

Although anxiety is common in lupus, the disease process can itself lead to severe disabling anxiety. Early recognition, multidisciplinary approach, and prompt treatment are essential for adequate patient care.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zhang L, Fu T, Yin R, Zhang Q, Shen B. Prevalence of depression and anxiety in systemic lupus erythematosus: A systematic review and meta-analysis. BMC Psychiatry 2017;17:70.  Back to cited text no. 1
    
2.
Hawro T, Krupińska-Kun M, Rabe-Jabłońska J, Sysa-Jędrzejowska A, Robak E, Bogaczewicz J, et al. Psychiatric disorders in patients with systemic lupus erythematosus: Association of anxiety disorder with shorter disease duration. Rheumatol Int 2011;31:1387-91.  Back to cited text no. 2
    
3.
Ishikura R, Morimoto N, Tanaka K, Kinukawa N, Yoshizawa S, Horiuchi T, et al. Factors associated with anxiety, depression and suicide ideation in female outpatients with SLE in Japan. Clin Rheumatol 2001;20:394-400.  Back to cited text no. 3
    
4.
Emmer BJ, van der Grond J, Steup-Beekman GM, Huizinga TW, van Buchem MA. Selective involvement of the amygdala in systemic lupus erythematosus. PLoS Med 2006;3:e499.  Back to cited text no. 4
    
5.
Bai R, Liu S, Zhao Y, Cheng Y, Li S, Lai A, et al. Depressive and anxiety disorders in systemic lupus erythematosus patients without major neuropsychiatric manifestations. J Immunol Res 2016;2016:2829018.  Back to cited text no. 5
    


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