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Other manifestations of CNS involvement, such as psychosis, also may need
inpatient evaluation. Listeria monocytogenes may cause indolent meningitis that is
clinically indistinguishable from organic brain syndromes. Similarly, it may be difficult
to determine whether psychosis is secondary to corticosteroid therapy; steroids are
most likely to induce an altered sensorium in patients with underlying psychiatric
disease. Clinicians should aggressively pursue a diagnostic evaluation, including
lumbar puncture and imaging procedures, so appropriate therapy may be instituted as
expeditiously as possible. When psychosis due to SLE is suspected, psychotropic drugs
(e.g., haloperidol 0.025 to 0.05 mg/kg/day in divided doses) may be used along with
large doses of corticosteroids for 1 to 2 weeks. If there is no improvement, the steroid
dose may be reduced gradually in an attempt to rule out steroid-induced psychosis.
Transverse myelitis is a rare complication of SLE believed to result from vascular
compromise of the spinal cord. Patients note acute onset of pain and weakness, and
they may develop incontinence. Physical examination is remarkable for weakness or
flaccid paralysis below the level of the functional transection. In a high percentage of
cases, the process is associated with a circulating lupus anticoagulant or
antiphospholipid antibodies. Prognosis is related to the duration of symptoms prior to
initiation of therapy, and favorable outcomes are only possible with urgent intervention.
Thus, once infection and hematoma are excluded with appropriate imaging procedures
and lumbar puncture, pulse doses of IV methylprednisolone (30 mg/kg over 1 to 2
hours), anticoagulation with IV heparin, and other immunosuppressive agents should
be administered.
Pulmonary Complications. Pleural effusion is the most common pulmonary
manifestation of SLE. Pleural effusion is often bilateral and small, although
occasionally it may be massive. The child is often ill with acute manifestations of
systemic disease, such as fever, fatigue, and poor appetite. Symptoms may be minimal
or absent; in the presence of a moderate or large effusion, the patient may have dyspnea
and tachypnea.
If the child has a previous history of pleurisy and there are no concerns about
infection, outpatient management may be possible for small pleural effusions.
Increasing the corticosteroid dose or adding an NSAID such as indomethacin (0.5 to 2

mg/kg/day) may be adequate therapy, but arrangements must be made for close followup. Thoracentesis is often necessary (i) to relieve symptoms, (ii) for diagnosis, or (iii)
to reveal any underlying lesions obscured by the effusion. Pleural effusions caused by
SLE usually are exudative, with elevated protein levels and cell counts, primarily
neutrophils early and lymphocytes later, with normal glucose and the presence of
ANAs.
Pulmonary hemorrhage is a potentially catastrophic complication of SLE,
particularly in the pediatric age group. Early recognition and treatment are critical. A
hemorrhage may be related to the disease itself (e.g., pulmonary vasculitis), to the