A Rare Confluence of Challenges: Lupus Cerebritis with Balint Syndrome Complicated by Spontaneous Subarachnoid Hemorrhage – A Unique Case Report
Juliana Cazzaniga1, Cesar Jara Silva Acosta2, Solomon Nittala2
1Florida International University Herbert Wertheim College of Medicine, 2Neurology, Larkin Community Hospital Palm Springs Campus
Background:
Lupus cerebritis, a neuropsychiatric manifestation of systemic lupus erythematosus (SLE), is a systemic autoimmune disease characterized by the production of autoantibodies, resulting in a wide spectrum of clinical manifestations affecting multiple organ systems. Neuropsychiatric involvement, a recognized complication of SLE, has a further distinct subset known as Lupus Cerebritis (LC) that involves inflammation within the CNS and can manifest as cognitive impairment, mood disorders, seizures, and a variety of neurological deficits. Balint syndrome, a rare neurological disorder first described by Rezső Bálint in 1909, is characterized by a triad of symptoms: simultanagnosia, optic ataxia, and oculomotor apraxia. Among the myriad of neurological complications of LC, the coexistence of Balint syndrome is an exceedingly rare and scarcely documented occurrence. Here we present a case with an unexpected twist: the simultaneous presence of spontaneous subarachnoid hemorrhage (SAH), a catastrophic event not commonly associated with lupus cerebritis. and an association that is virtually unprecedented in the literature. The concomitant presence of these three distinct entities presents a diagnostic and therapeutic challenge that demands careful consideration.
Results:
A 35-year-old female with a history of lupus, seizures, and migraines who had been lost to follow-up presented to the emergency department complaining of a severe headache associated with vomiting. In the ED, she experienced a witnessed generalized tonic-clonic seizure prompting admission for further evaluation. MRI Brain without contrast showed patchy cortical/subcortical T2/FLAIR white matter hyperintensities of the bilateral frontal, parietal, and occipital lobes suspicious for Lupus Cerebritis. On the second day of admission, the patient developed a new onset right-gaze preference and left-sided hemiparesis. Follow-up CTA Head and Neck was concerning for spontaneous subarachnoid hemorrhage. During the hospital course, the patient developed optic ataxia with oculomotor apraxia, simultagnosia, and nystagmus, a constellation of symptoms consistent with Balint Syndrome.