7.3.3 Headache attributed to other non-infectious inflammatory intracranial disease

Identification: Sex/Age: Female, 28 years.

History: Systemic lupus erythematosus (SLE) under treatment with prednisone and hydroxychloroquine for 3 years.

Current Medications: Prednisone 10 mg/day, hydroxychloroquine 400 mg/day.

History of Present Illness (HPI): Main symptom: Diffuse headache for 1 week, with gradual onset.

Pain characteristics:

Location: Bifrontal and occipital.

Character: Continuous pressure.

Intensity: 7/10.

Aggravation: Worsens with eye movements and upon waking.

Associated symptoms:

Blurred vision.

Nausea without vomiting.

Intense fatigue.

Relevant factors: History of SLE with recent inflammatory activity (arthralgias and skin rash).

Physical/Neurological Examination: General: Patient conscious, but with marked asthenia.

Neurological:

Cranial nerves: Right diplopia (partial paralysis of the VI cranial nerve).

Fundoscopy: Mild bilateral papilledema.

Meningeal signs: Negative.

Muscle strength and sensation: Normal.

Complementary Exams: Magnetic Resonance Imaging of the Brain:

Findings: Leptomeningeal thickening with post-contrast enhancement in frontoparietal regions.

Cerebrospinal Fluid (CSF):

Lymphocytic leukocytosis (25 cells/mm³).

Elevated proteins (80 mg/dL).

Normal glucose levels.

Cultures negative for bacteria, viruses, and fungi.

Laboratory:

Anti-double-stranded DNA positive (↑↑).

ESR and CRP elevated.