Rare Cause of Seizures, Renal Failure, and Gangrene in an 83-Year-Old Diabetic Male

We report an 83-year-old diabetic male who presented with acute-onset renal failure, seizures, psychosis, pneumonia, and right foot gangrene. Investigations revealed thrombocytopenia, CSF lymphocytosis, ANA and dsDNA positivity, hypocomplementemia, and pneumonitis following which he was treated with pulse methylprednisolone. He was treated for Pseudomonas-related ventilator-associated pneumonia, candiduria, and E. coli-related bedsore infection prior to discharge. He was discharged at request and died 17 days later due to a respiratory infection. 1. Introduction Onset of systemic lupus erythematosus (SLE) after the age of 50 (late-onset SLE) constitutes 6–18% of the lupus population [1]. Most cases of lupus over 65 years have been described as case reports. Renal failure is the initial presentation only in 25% patients of SLE [2]. Neuropsychiatric SLE (NSLE) in the elderly is very rare. Infections, malignancies, and atherosclerotic disease account for most deaths in SLE patients [3]. Here we describe an 83-year-old diabetic who presented with acute-onset seizures, psychosis, pneumonitis, foot gangrene, and renal failure and improved with immunosuppressive therapy for SLE but succumbed to another respiratory infection 17 days after discharge from hospital. 2. Case This 83-year-old diabetic of 10 years’ duration (on metformin 750？mg OD) was brought from another hospital by his relatives for mechanical ventilation. Fifteen days prior, he had complained of fatigue and anorexia and was admitted in a local nursing home where he was told to have early renal failure (creatinine 202？μmol/L). Four days later he had had a generalized tonic-clonic seizure for which he was taken to the referring hospital for management. Computed tomography (CT) of brain was normal and the patient was commenced on phenytoin; he was uncooperative for magnetic resonance imaging (MRI). He had developed acute psychosis and delirium in hospital and was managed with risperidone. Three days later he was intubated for altered sensorium and respiratory distress following acute cough, breathlessness, and fever. He was mechanically ventilated and administered ceftriaxone and metronidazole; his seizures remained under control but altered sensorium persisted. During his stay in intensive care, he developed discoloration of his right foot and warfarin had been initiated. His renal parameters had continued to worsen (creatinine 350？μmol/L) and his relatives requested discharge and brought him to our hospital. He was a cigar smoker (>40 years) and drank occasionally. He had had a left hip fracture