New-Onset Generalized Seizure as the Initial Manifestation of Neuropsychiatric SLE (NPSLE)

Background: Neuropsychiatric SLE presents with a wide range of neurological features. Seizures occur in up to 20% of SLE patients but rarely serve as the initial presentation. Early differentiation from infectious meningo-encephalitis is essential, as timely immunosuppressive therapy improves outcomes.

Methods: A case-based clinical evaluation approach was applied, including neurological assessment, laboratory investigations, CSF analysis, MRI brain, EEG, systemic imaging, immunological testing, treatment with high-dose steroids and cyclophosphamide, and follow-up monitoring.

Results: A 19-year-old woman presented with new-onset generalized tonic–clonic seizures following a febrile illness. CSF showed mild lymphocytic pleocytosis with negative infectious markers. MRI revealed bilateral subcortical T2/FLAIR hyperintensities. She had nephrotic-range proteinuria, serositis, hypertension, and ANA positivity. The combined findings confirmed NPSLE with lupus nephritis. Treatment with IV methylprednisolone and Euro-Lupus cyclophosphamide led to rapid neurological recovery, extubation within 48 hours, and no further seizures on follow-up.

Conclusion: Seizures may be the first manifestation of NPSLE. Young females presenting with seizures and systemic signs such as hypertension, proteinuria, or serositis should be evaluated for lupus cerebritis. Early recognition and immunosuppression are crucial to prevent long-term neurological morbidity.

Dr. Rashid Usman is a Specialist Registrar in Neurology, currently working at Akbar Niazi Teaching Hospital, Islamabad. He has completed his MBBS in 2016-17 and after House job of one year, pursued his training in internal medicine of 2 years and then specialty training in neurology from Fauji foundation hospital, Rawalpindi (2019-2023). He is keen to further pursue his career in stroke medicine, for which he is enrolled in University of Alberta, Canada from July, 2026.