Central Nervous System (CNS) infections in Systemic Lupus Erythematosus (SLE) are a known risk; however, subdural empyema represents an exceptionally rare and life-threatening intracranial infection, particularly as an initial presentation of the disease. Mixed Autoimmune Hemolytic Anemia (AIHA), defined by the presence of both warm and cold antibodies against the patient’s own erythrocytes, is a rare hematological entity. We report a case of a 19-year-old female who presented with a one-month history of severe headache, blurring of vision, and intermittent fever. Although she was initially stable, her clinical course deteriorated on the second day of admission with the onset of focal seizures affecting the left upper limb. Preliminary investigations revealed severe anemia (Hemoglobin 3.3 g/dL) and thrombocytopenia. A peripheral blood smear demonstrated anisopoikilocytosis and schistocytes. Biochemical markers indicated hemolysis with elevated lactate dehydrogenase (LDH) levels (1745 U/L) and indirect hyperbilirubinemia. Immunological evaluation confirmed mixed AIHA with a positive monospecific Direct Antiglobulin Test (DAT) for both IgG and C3. Further serology was reactive for ANA and anti-dsDNA, confirming a diagnosis of SLE. Magnetic Resonance Imaging (MRI) of the brain identified a subdural empyema in the left frontoparietal region accompanied by dural venous sinus thrombosis. The patient was managed aggressively with broad-spectrum intravenous antibiotics, anticoagulation, and pulse steroid therapy, resulting in significant clinical improvement. This case highlights the diagnostic complexity of SLE when it presents simultaneously with severe autoimmune cytopenias and rare intracranial infections.
G. Rathnakumar, A. Ravi, R. Chandraganesan, S. S. Akash Kumar* (Sun,) studied this question.