Mack Axel, Pfeiffer Christiane, Schneider E Marion, Bechter Karl
Department of Psychiatry and Psychotherapy II, University Ulm/Bezirkskrankenhaus Guenzburg, Guenzburg, Germany.
Department of Dermatology and Allergology, University Hospital Ulm, Ulm, Germany.
Front Psychiatry. 2017 Jul 27;8:131. doi: 10.3389/fpsyt.2017.00131. eCollection 2017.
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.
我们观察了一例患有复发缓解型精神分裂症谱系障碍超过25年的病例，其主要症状在更具抑郁性、更具分裂情感性或更典型的精神分裂症综合征之间有所不同。患病阶段反复伴有轻微皮肤病变，最初被归类为混合性组织疾病。精神病性阶段在数年中呈时轻时重状态。在后来的一次复发期间，皮肤受累严重，被归类为可能是对精神药物的过敏反应；这种全身性皮疹经皮质类固醇治疗和硫唑嘌呤后迅速消退。在持续使用硫唑嘌呤和低剂量抗精神病药物的情况下，患者完全缓解，精神状态健康达16年。当因怀孕停用硫唑嘌呤后，在几周内出现了类似精神分裂症的异常严重复发，并伴有最严重的皮肤病变，随后需要住院接受两年的精神科治疗。最终，诊断为系统性红斑狼疮加神经精神性狼疮。2013年的一份脑脊液样本显示有可疑的生物标志物，与精神分裂症和情感谱系障碍患者的脑脊液细胞因子谱相符，提示存在轻度神经炎症。复发后不久重新开始了复杂的免疫抑制治疗，但仅取得部分成功。然而，令人惊讶的是，给予贝利尤单抗（附加治疗）后，精神病和皮肤病变（同时）缓解。还结合一般观点讨论了这一复杂、长期病程的具体细节，特别是关于这例看似合并有轻微自身免疫迹象的精神分裂症病例是否代表一种全身性和中枢神经系统内具有变异表现的新兴自身免疫性疾病的问题，尽管其非典型地主要表现为精神分裂症谱系障碍。
