Psychosis and Pericardial Effusion in Neuropsychiatric Systemic Lupus Erythematosus: Diagnostic Challenges in a Language-Discordant Encounter

Neuropsychiatric systemic lupus erythematosus (NPSLE) is a diagnostically complex manifestation of systemic lupus erythematosus (SLE) that may initially present with significant psychiatric symptoms, contributing to delayed recognition and treatment. We describe a 36-year-old non-English-speaking female patient with a recent history of intermittent medical and psychiatric encounters over 1 year, during which progressive psychosis was attributed to a primary psychiatric illness. Her course was characterized by fragmented care across institutions, limited collateral history, language discordance, and diagnostic anchoring on psychiatric diagnosis despite evolving systemic findings. Several weeks after surgical management of a large pericardial effusion, the patient presented to the emergency department with acute psychiatric decompensation marked by hallucinations and behavioral abnormalities. She was admitted for cardiac monitoring and treated for presumed primary psychosis. Subsequent multidisciplinary reassessment, delayed acquisition of outside records, and neuroimaging revealing diffuse parenchymal enhancement raised concern for NPSLE. Once lupus-directed immunosuppressive treatment was initiated, the patient demonstrated substantial improvement in psychiatric symptoms. This vignette highlights the diagnostic challenges of autoimmune disease presenting with psychiatric manifestations and underscores the importance of systematic collateral assessment, cross-institutional communication, and interdisciplinary collaboration in reducing diagnostic delay.