Abstract
We observed a case over 25 years of relapsing–remitting schizophrenic spectrum disorder, varying regarding the main symptomatology between more depressive or more schizoaffective or rather typical schizophrenic syndrome. Diseased phases were repeatedly accompanied by minor skin lesions, which were initially classified as mixed tissue disorder. Psychotic phases were waxing–waning over years. During one later relapse, skin involvement was severe, classified to likely represent an allergic reaction to psychopharmaca; this generalized exanthema remitted rapidly with cortisone treatment and azathioprine. Under continued azathioprine and low dose neuroleptics, the patient remitted completely, appearing psychiatrically healthy for 16 years. When azathioprine was set off due to pregnancy, an extraordinary severe relapse of schizophrenia like psychosis accompanied by most severe skin lesions developed within a few weeks, then requiring 2 years of psychiatric inpatient treatment. Finally, a diagnosis of systemic lupus erythematodes plus neuropsychiatric lupus was made. A single CSF sample in 2013 showed suspicious biomarkers, matching with CSF cytokine profiling in schizophrenic and affective spectrum disorder patients and indicated mild neuroinflammation. Complex immune suppressive treatment was reinitiated short after relapse, but was only partially successful. However, surprisingly the psychosis and skin lesions remitted (in parallel) when belimumab was given (add-on). The very details of this complicated, long-term disease course are discussed also with regard to general ideas, in particular with respect to the question if this case of seemingly comorbid schizophrenia with minor autoimmunity signs represented a case of one emerging autoimmune disorder with variant manifestations systemically and within the CNS, though atypically with predominant appearance as a schizophrenia spectrum disorder.
Highlights
Schizophrenia is understood as a partly heritable brain disease, recent interesting findings showing alleles of the complement component C4 genes play a role in both in the CNS and the immune system [1]
The relative risk of schizophrenia for an Schizophrenia or Atypical Lupus Erythematosus individual with a history of autoimmune disease in themselves or in their family is elevated by about 45%
The disease course in this patient was atypical, as her psychotic phases were often accompanied by appearance of minor non-specific skin lesions on the trunk and limbs
Summary
Schizophrenia is understood as a partly heritable brain disease, recent interesting findings showing alleles of the complement component C4 genes play a role in both in the CNS and the immune system [1]. During one particular psychotic relapse she developed severe skin efflorescences, which were treated with cortisone and later azathioprine Under this regimen skin improved rapidly and surprisingly after this particular inpatient treatment, the patient remained psychiatrically well with few exceptions over many years. After discontinuing azathioprine, she rapidly relapsed and for the first time the criteria of an established autoimmune disorder, systemic lupus erythematosus (SLE), were fulfilled and could be even extended to neuropsychiatric lupus erythematosus (NPSLE). The question discussed in this single case, is whether the patient suffered from the two unrelated disorders of schizophrenia and SLE, or an atypical course of a not clearly defined autoimmune disorder with early predominant psychiatric and late neuropsychiatric manifestations, with minor systemic manifestations and late fulfilling criteria of SLE/NPSLE
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