Case report

A thirty eight year old woman with insulin dependent diabetes mellitus and systemic lupus erythematosus (SLE) was admitted with a two day history of fever, rigors, and diarrhoea. SLE was diagnosed at the age of 18 years when she presented with joint pain, a positive antinuclear antibody (ANA), and severe autoimmune thrombocytopenia, which was treated with corticosteroids. At no stage of her illness did she have evidence of renal, central nervous system, muscle or skin involvement. She had also suffered four miscarriages in association with anticardiolipin antibodies. There was no history of arterial or venous thrombosis and her disease had been inactive for a number of years.

When reviewed as an outpatient, two months before admission, she was well with no clinical manifestations of SLE. ANA was positive (1:160), extractable nuclear antigen screen negative, C3 141g/l (88–201), C4 23.1g/l (16–47), DNA binding 3I U/l (0–7), anticardiolipin antibody was 30 gpl units (<10) and lupus anticoagulant test was not performed. Full blood count, including lymphocyte count and blood film, was entirely normal. She was not receiving immunosuppressive or corticosteroid therapy.

On admission to the Infection Unit she was febrile at 40°C, with a tachycardia of 130/min, blood pressure 65/38 mm Hg, and tenderness over the frontal sinuses. There was no neck …