An evaluation of the diagnostic performance of the triphasic bone scintigraphy in patients suspected of aseptic total knee arthroplasty loosening.

Background: Total Knee Arthroplasty (TKA) is a widely conducted and successful orthopedic procedure. However, aseptic loosening, a common cause of TKA failure, necessitates revision surgery. Diagnostic accuracy of triphasic bone scintigraphy, a common imaging modality for aseptic loosening detection, remains controversial. This study investigated the diagnostic accuracy of bone scintigraphy when separately evaluated by a nuclear physicist and an orthopedic surgeon, and the interrater reliability between the two. Methods: Patients undergoing knee revision surgery due to suspected aseptic loosening at three medical centers from 2006 to 2023 were included. Relevant demographic, clinical, and procedural data were extracted from the records. The bone scintigraphy results as noted by the nuclear physicist and orthopedic surgeon were used as index test and intraoperative findings of loosening were used as reference tests. Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were calculated, and kappa's agreement was assessed. Results: Out of 611 revision TKAs, 59 cases were analyzed. The nuclear physicist's evaluation of bone scintigraphy had a sensitivity of 73 %, specificity of 0 %, positive predictive value of 93 %, negative predictive value of 0 %, and diagnostic accuracy of 69 %. The orthopedic surgeon's evaluation showed higher sensitivity, specificity, positive and negative predictive values, and an accuracy of 84 %. Agreement levels were moderate (kappa = 0.46) between the nuclear physicist's and orthopedic surgeons evaluation. Interpretation: The diagnostic accuracy of bone scintigraphy for aseptic loosening is 84 % when evaluated by the orthopedic surgeon compared to 69 % for the nuclear physicist's evaluation. Kappa's agreement between the two was moderate.

Dramatic Failure of an OXINIUM Total Knee Arthroplasty With a Massive Pseudotumor Formation.

Since the early 2000s, oxidized zirconium implants have emerged as a valuable option in total hip and knee arthroplasty due to their wear resistance and suitability for patients with metal hypersensitivity. The surface of these components is created through a heating and oxidation process of a zirconium alloy, resulting in a thin layer with favorable wear properties. However, there have been few reports of severe metallosis resulting from inadvertent wear of oxidized zirconium components through various mechanisms, including dissociation of the polyethylene liner and joint instability. We present a case involving a dramatic failure of an oxidized zirconium total knee arthroplasty, necessitating a staged revision arthroplasty.

Retaining a Well-fixed Cone During Revision Total Knee Arthroplasty: Surgical Technique and Outcomes.

Metaphyseal cones are frequently used in revision total knee arthroplasties (TKAs). However, during subsequent aseptic re-revisions, removing a well-fixed cone can be difficult. One innovative option is to retain the well-fixed cone and cement a new, stemmed revision component through the retained cone, yet minimal data exist on this technique. We describe a technique for retaining a well-fixed cone during re-revision TKA and report outcomes in 6 patients with 6 well-fixed metaphyseal cones. At a mean of 4 years follow-up, no retained cones with a new femoral or tibial component with stems were revised and there was no radiographic evidence of aseptic loosening. These early data suggest that retaining a well-fixed cone can be safe in re-revision TKA to minimize morbidity associated with cone removal. Level of evidence: IV (retrospective study).

Cement Viscosity and Application Time Lead to Significant Changes in Cement Penetration and Contact Surface Area.

Background: Application time and viscosity are factors that can significantly affect the properties of bone cement and implant fixation. The aim of this study was to investigate the influence of different application times of 2 different cements on mechanical parameters, cement interdigitation, and cement distribution. Methods: P.F.C. Sigma tibial trays were cemented with high-viscous Palacos R and medium- to low-viscous Simplex P in an open-cell model. The application was performed at different times within the manufacturer's specifications. Cement interdigitation and micromotion were measured with computed tomography scan using a novel method. Results: Significant differences of insertion forces were found at all times of cement application. Cement penetration decreased with increasing pressure and viscosity. No significant differences were shown for micromotion between Palacos R and Simplex P except for an increase for Simplex P from 3 to 7 minutes at the bone-cement interface. Simplex P appeared to trap air at the implant-cement interface at 3 minutes and increased at 7 minutes. Conclusions: Cement distribution and intrusion of Palacos R and Simplex P decreased with time. Simplex P trapped air at the implant-cement interface, decreasing the amount of contact at the implant-cement interface, which is worrisome for long-term implant fixation. Given the significant changes in cement properties after mixing, it is necessary for surgeons to understand the viscosity and timing of cement application to achieve optimal cement penetration and surface contact area to potentially decrease implant loosening. High-viscous Palacos R should be applicated immediately with doughing time and medium-viscous Simplex P for about 4 minutes considering a threshold of minimum pressure.

Tranexamic Acid as a Preventive Strategy Against Periprosthetic Joint Infection in Aseptic Revision Arthroplasty: A Comprehensive Review.

Periprosthetic joint infection (PJI) is a severe complication following joint replacement surgeries, particularly in aseptic revision arthroplasty, where infection rates are higher compared to primary procedures. The extended surgical time, increased blood loss, and the presence of scar tissue contribute to the higher susceptibility to PJI in revision surgeries. Tranexamic acid (TXA), a synthetic antifibrinolytic agent, is widely used in orthopaedic surgery to reduce intraoperative and postoperative bleeding. By stabilising blood clots and reducing the need for blood transfusions, TXA improves patient outcomes and reduces complications related to excessive bleeding. Emerging evidence suggests that TXA may also play a role in reducing PJI, as minimising bleeding and haematoma formation can reduce bacterial colonisation and blood transfusions are associated with increased infection risks due to immunomodulation. This review explores the potential of TXA as a preventive strategy against PJI in aseptic revision arthroplasty, evaluating its mechanisms, clinical applications, and current evidence. While TXA's efficacy in reducing blood loss is well-established, its role in infection prevention, particularly through indirect mechanisms such as limiting haematoma formation, warrants further investigation. By incorporating TXA into multimodal strategies aimed at reducing PJI, surgeons can potentially improve patient outcomes and reduce the financial burden on healthcare systems. This review provides a comprehensive examination of the available data on TXA's role in preventing PJI in revision arthroplasty, with an emphasis on understanding its mechanisms and identifying gaps in current knowledge that require further research.

Increased revision rates in shoulder arthroplasty following shoulder arthroscopy.

Introduction: Total shoulder arthroplasty (TSA) and reverse TSA (rTSA) are successful treatments for end-stage shoulder arthritis. However, it is unknown whether prior arthroscopy is associated with an increased risk for revision surgery. This study investigates if undergoing a shoulder arthroscopy in the year prior to primary arthroplasty increases risk of revision surgery within 2 years. Methods: Patients who underwent TSA or rTSA between 2005 and 2017 were identified in a natinal claims database and stratified into two cohorts: (1) individuals with a history of shoulder arthroscopy prior to arthroplasty and (2) individuals with no documented history of arthroscopy prior to arthroplasty. These cohorts were propensity matched based on demographic and comorbidity factors. Univariate analysis was used to determine differences in revision rates, aseptic loosening, periprosthetic fracture, and infection between the two cohorts. Results: Seven hundred and eighty-eight patients were successfully matched from the two cohorts. Revision surgery (3.4% vs. 1.4%, p = 0.001) and aseptic loosening (2.2% vs. 0.8% p = 0.021) were significantly more common in the arthroscopy cohort. Periprosthetic fracture and periprosthetic infection were not found to be significantly different between cohorts. Discussion: Shoulder arthroscopy in the year prior to shoulder arthroplasty is associated with an increased risk of complications, including revision and aseptic loosening.

Revision Total Elbow Arthroplasty.

Despite improvements in our understanding of elbow biomechanics and implant design, rates of complications and early revision are higher following total elbow arthroplasty (TEA) compared with shoulder and lower-extremity arthroplasty. Revision TEA remains a standard but technically challenging procedure with the potential for substantial morbidity. This review discusses the diagnosis and management of the failed primary TEA. Current concepts related to surgical treatment with revision TEA indicated for prosthetic joint infection, periprosthetic fracture, and aseptic osteolysis will be reviewed. In addition, strategies and adjunctive procedures for dealing with bone loss in the revision setting will be discussed.

Isolated aseptic loosening in total knee arthroplasty: a comprehensive 10-year review of partial vs. total component revisions.

BACKGROUND: In total knee arthroplasty (TKA), isolated aseptic loosening (IAL) requires the replacement of prosthetic components, with ongoing debate regarding the effectiveness of partial component revision (PCR) compared to total component revision (TCR). This study aims to compare implant survival and surgical outcomes between PCR and TCR in the context of IAL. METHODS: This retrospective study analyzed data from 285 patients who underwent revision TKA for IAL between January 2000 and December 2013. After applying exclusion criteria, 112 patients were included in the analysis-60 undergoing TCR and 52 undergoing PCR. RESULTS: PCR was associated with shorter operative times and hospital stays compared to TCR, alongside significant differences in the choice of revision prostheses. Although the prosthesis failure rates were comparable between the groups (13.6% for TCR and 18.33% for PCR), significant risk factors for failure were identified, including a canal filling ratio (CFR) below 0.8 and a discrepancy over 0.2 between CFR views. However, no significant differences in overall survivorship were observed between the groups. CONCLUSIONS: Both PCR and TCR provide similar survival rates and clinical outcomes for managing IAL in TKA. PCR provides advantages in terms of surgical efficiency and patient recovery, while reducing the need for more constrained prosthetic solutions. The study identifies CFR as a critical predictor of prosthesis failure, highlighting the importance of detailed preoperative planning and implant selection. These findings contribute valuable insights for improving revision strategies in IAL, enhancing surgical outcomes in TKA. LEVEL OF EVIDENCE: III.

Osteoporosis May Not Be an Absolute Contraindication for Cementless Total Knee Arthroplasty.

BACKGROUND: Cementless total knee arthroplasty (TKA) has received growing interest, particularly in younger populations, due to potential long-term survivability and improved bone preservation. Poor bone stock, as seen in osteoporosis, is considered a contraindication for this technique. This study evaluated whether osteoporotic patients < 75 years undergoing cementless TKA demonstrate similar 1) implant-related complications, 2) medical complications, 3) readmission rates, and 4) 3-year implant survivability. METHODS: A retrospective query of a national administrative claims database was performed between 2010 and 2022 for patients less than or equal to 75 years old who have osteoporosis and underwent primary TKA. Osteoporotic patients were divided into cementless and cemented cohorts, and propensity scores were matched based on age, sex, obesity, and the Charleston Comorbidity Index (CCI). Matching produced 7,923 patients (1,321 uncemented, 6,602 cemented). Multivariate logistic regressions evaluated the following outcomes: 90-day and 2-year implant-related complications, 90-day postoperative medical complications, and 90-day readmissions. Kaplan-Meier survival analysis was conducted to assess 3-year all-cause revision implant survivability. The significance threshold was set to P < 0.01 to minimize type 1 bias. RESULTS: There were no statistically significant differences in implant-related complications, medical complications, readmissions, and lengths of stay between cementless and cemented TKA groups. Kaplan-Meier analysis demonstrated statistically similar 3-year survivability between cohorts (cemented: 97.6%, CI [confidence interval] 96.6 to 98.5; cementless: 97.2%, CI 96.7 to 97.7; P = 0.472). CONCLUSION: Patients who have osteoporosis have equivalent medical and implant-related complications as well as 3-year implant survival following cementless TKA compared with a cemented technique. Our results support cementless TKA as a viable option for patients < 75 years, regardless of prior diagnosis of osteoporosis. Intraoperative decisions regarding bone quality are still necessary to discriminate between those who are candidates for cementless TKA with those who are not.

No Difference in Survivorship Following Primary Total Hip Arthroplasty Using Ultra-Porous Acetabular Cups and Crosslinked Polyethylene With and Without Acetabular Screws in a Large US Healthcare System.

INTRODUCTION: Modern cementless acetabular cups for total hip arthroplasty (THA) typically have screw options. Historically, screws were thought to improve stability, but came at the cost of pathways for osteolysis. Modern cups and liners may have made both concerns obsolete, and the utility of screws are now contested. We sought to determine modern implant survivorship relative to screw use. METHODS: We conducted a cohort study. A US healthcare system's Total Joint Replacement Registry was used to identify patients ≥18 years who underwent uncomplicated primary THA for osteoarthritis (2010 to 2021) with an ultra-porous cup and cross-linked polyethylene liner, with- or without one to two acetabular screws. The primary outcome was acetabular revision for aseptic loosening. Secondary outcomes were aseptic revision for acetabular fracture and any revision for acetabular/femoral loosening and periprosthetic fracture. Multiple Cox proportional hazard regression was used to evaluate revision risk. There were 46,785 THAs identified. Screw use declined from 65.3 to 49.9%. RESULTS: No difference was observed in 10-year revision risk for acetabular loosening (0.2 versus 0.1%, hazard ratio [HR] 1.97, 95% confidence interval [CI] = 0.84 to 4.59, P = 0.119). There was one revision for acetabular fracture with and three revisions without screws. There was no difference in risk of overall acetabular or femoral revision, loosening, or periprosthetic fracture. There remained no difference in acetabular-sided loosening between routine screw users and non-users (0.15 versus 0.06%, HR 1.26, 95% CI 0.42 to 3.75, P = 0.683). CONCLUSIONS: In this study of survivorship following routine uncomplicated primary THA with modern cups and liners, screw usage patterns were associated with neither an advantage nor disadvantage - neither screw usage nor avoidance was associated with differences in acetabular loosening revision risk. Screw use was not associated with harm but remains debatable if there is an added benefit.

Single-Taper Conical Tapered Stem in Total Hip Arthroplasty for Primary Osteoarthritis: A Comparative Long-Term Registry Evaluation.

Background/Objectives: Single-taper conical tapered stems (STCTSs) are possible options for femoral reconstruction in THA performed for primary osteoarthritis, but outcomes are poorly ascertained. A specific STCTS in THA performed for primary osteoarthritis was investigated and compared to a control group including all the other cementless stems, aiming to assess the following: (1) the survival rates of the two cohorts and the hazard ratios for failure; (2) the survival rates and the hazard ratios for failures for stem failure, stem aseptic loosening, and periprosthetic fracture. Methods: A regional arthroplasty registry study evaluating a specific STCTS in THA performed for primary osteoarthritis was designed. A control group including all the other cementless stems was considered. Results: In total, 1773 STCTSs were compared to 37,944 cementless stems. The cumulative survivorship of the STCTS cohort was 95.6% at 10 years and 92.7% at 15 years, which was not different to the control group (p = 0.252). After age stratification, the hazard ratio for STCTS failure was not different to the control group. With stem revision as the endpoint, the STCTS cohort outperformed the control group (at 10 years, 98% versus 96.8%; p < 0.001). The STCTSs achieved better survival rates in females <65 years (p = 0.023). With stem aseptic loosening as the endpoint, the survival rates did not differ between the two cohorts (p = 0.085), as well as the adjusted hazard ratios (p = 0.264). With periprosthetic fracture as the endpoint, the survival rates were better for the STCTSs (p < 0.001). Conclusions: STCTSs in THA for primary osteoarthritis provided dependable long-term outcomes, not inferior to all the other cementless stems with various designs.

Geographical Disparities in the Distribution of Community Pharmacies Providing Aseptic Preparation Services in Japan.

Purpose: Providing medical, nursing, and welfare services in each community is becoming increasingly important as population ages in Japan, and the demand for aseptic preparation in community pharmacies is expected to increase. In this study, the disparity in the distribution of community pharmacies providing aseptic preparation services were examined to explore how the unequal distribution of the pharmacies can be improved in the future. Methods: The regional inequality of community pharmacies providing aseptic preparation services was evaluated using Gini coefficients. The regional distribution was evaluated using a geographic information system application. Results: Only 8.0% of all insurance community pharmacies in Japan provided aseptic preparation services. The Gini coefficient of pharmacies providing aseptic preparation services for the total population of each municipality was 0.410. The population coverage, within 16 km of pharmacies providing aseptic preparation services, was 96.5% of the total population. The residential grid coverage, within 16 km of the pharmacies, was 75.2% of the total network, approximately one quarter not covered. It is estimated that the coverage ratios will improve by some percentage by 2050, although the projected population in 2050 is expected to decrease by approximately 20%. Conclusion: The current number and distribution of pharmacies providing aseptic preparation services are inadequate, and measures need to be taken to avoid future problems.

Robotic assistance improves success of cementless component fixation in one total knee arthroplasty system.

INTRODUCTION: New cementless implant designs in total knee arthroplasty (TKA) have begun to shift the longstanding practice of cemented fixation. With aseptic loosening a leading cause for revision of cementless implants, initial osteointegration is critical for component survivorship. Robotic-assisted TKA (RA-TKA) has shown promising results in recent literature at improving component accuracy. The current study aims to evaluate if robotic assistance affects the success of cementless fixation in primary TKA. METHODS: 445 cementless primary TKA components from one manufacturer implanted by five surgeons between June 2018 and October 2022 were retrospectively reviewed. Those with minimum one-year follow-up were analyzed. Femoral and tibial components were reviewed separately and grouped based on whether manual or RA-TKA from the same manufacturer was performed. Fisher's exact test was used to analyze if aseptic loosening rates were different between the two techniques. RESULTS: 373 (82%) cementless components from a single knee system were included. 146 femoral and 103 tibial components were implanted using RA-TKA, while 63 femoral and 61 tibial components were implanted manually. At a mean follow-up of 18 months (range, 12 to 51 months), successful fixation was achieved in 96.2% of all components. No femoral components from either group were revised due to aseptic loosening. Four manually implanted vs. no robotically assisted tibial components were revised due to aseptic loosening (6.6% vs 0.0%; P = 0.038). CONCLUSION: The performance of modern cementless femoral components was excellent with or without robotic assistance, however RA-TKA improved the survivorship of the same system's cementless tibial component. LEVEL OF EVIDENCE: Level III.

Will Mobile-Bearing Total Knee Arthroplasty Be Lost to History? A Comparative Study of Long-Term Follow-Up.

Mobile-bearing (MB) total knee arthroplasty (TKA) implants were introduced as an alternative to fixed-bearing (FB) implants because of their theoretical advantages related to femorotibial rotational mismatch. The purpose of this study is to compare the clinical and radiologic outcomes of MB and FB TKA after approximately 13 years of follow-up. We compared the results of 88 patients with a mean age of 66 years who had received a rotating platform MB implant or a FB implant. The mean follow-up was 13.6 years. The patients were assessed clinically (VAS, ROM, KSS, WOMAC scores) and radiographically before and 13 years after operation. There were no statistically significant differences between the FB and MB groups in terms of clinical outcomes and radiological outcomes (p > 0.05 for all). Although the incidence of complications was higher in the MB group, the findings were not statistically significant compared to the FB group (p > 0.05 for all). Although there were no significant differences in the clinical and radiologic outcomes between the FB and MB groups, the possible higher risk of osteolysis or aseptic loosening in the MB group could be an important clinical implication when selecting the TKA implant.

Unsuspected Positive Intra-Operative Cultures in Aseptic Revision Hip Arthroplasty: Prevalence, Management, and Infection-Free Survivorship.

BACKGROUND: This study aimed to describe the management and outcomes of aseptic revision total hip arthroplasty (arTHA) with unsuspected intra-operative positive cultures (UPCs) compared to those with sterile cultures. METHODS: A single tertiary center's institutional database was retrospectively reviewed for arTHA from January 2013 to October 2023. Pre-operative Musculoskeletal Infection Society (MSIS) scores were assigned to patients based on available infectious workup, and those who met the criteria for periprosthetic infection (PJI), received antibiotic spacers, or had less than 1-year follow-up were excluded. Patients were grouped and compared according to intra-operative culture results: sterile cultures, one UPC with a new organism, one UPC with the same organism as prior PJI, ≥ two UPCs with different organisms, and ≥ two UPCs with the same organism. RESULTS: There was a total of 604 arTHAs included in this study, of which 0.8% [five of 604] had ≥ two UPCs with different organisms, 1.5% [9 of 604] had ≥ 2 UPCs with the same organism, 9.8% [59 of 604] had one UPC with a new organism, 0.2% [one of 604] had 1 UPC with an organism from prior PJI, and 87.7% [530 of 604] of patients had sterile cultures. When comparing 5-year infection-free survival between patients who had one UPC with a new organism and sterile cultures, there was no difference (P = 0.40); however, patients who had ≥ two UPCs with different organisms (P < 0.001), patients who had ≥ two UPCs with the same organism (P = 0.001), and patients who had one UPC of an organism from prior PJI (P < 0.001) had statistically worse infection-free survival compared to patients with sterile cultures. CONCLUSION: Infection-free survival at five years was similar between patients who had one UPC with a new organism and those who had sterile cultures; however, ≥ two UPCs and a history of PJI are both significant risk factors for re-revision for infection after arTHA.

Evaluation of conventional and CT-based radiostereometric analysis for inducible displacement measurements after total hip arthroplasty.

Though radiostereometric analysis (RSA) is the gold standard for migration tracking, computed tomography-based RSA (CT-RSA) does not require marker beads and is available for clinical adoption. This study investigated CT-RSA in comparison to RSA for assessing hip implant stability with inducible displacement (ID) examinations. Patients (n = 48) from a previous study returned to be re-examined for femoral stem stability with CT-RSA and RSA imaging. Implant migration since patients last follow-up was calculated as a measure of stability. ID was assessed between alternated leg rotation scans for CT-RSA and between supine and weight-bearing scans for RSA. Measurements from ID and double examinations were compared between CT-RSA and RSA. All stems were well-fixed with migration <0.2 mm/year. ID measurements were lower with CT-RSA than RSA for distal translation (mean difference = 0.122 mm, p < 0.0001), total translation (mean difference = 0.158 mm, p < 0.0001), and total rotation (mean difference = 0.449°, p < 0.0001). The ID and double exam were significantly different for total translation and total rotation for CT-RSA, and significantly different for medial, distal, and total translation, and total rotation for RSA. Precision ranged from 0.049 to 0.130 mm in translation and 0.061° to 0.220° in rotation for CT-RSA, and from 0.108 to 0.269 mm in translation and 0.151° to 0.670° in rotation for RSA. ID measurements from both CT-RSA and RSA were minimal, consistent for a cohort with well-fixed stems. CT-RSA demonstrated superior precision in all axes compared to RSA. Clinical Significance: Future work should explore the use of CT-RSA in patients with suspected loosening as a potential diagnostic tool.

An Impressive Response to Zoldronic Acid Treatment for Chronic Recurrent Multifocal Osteomyelitis: A Case Report.

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare, non-infectious inflammatory disease with a prevalence of 1 to 2/106, causing multiple lytic bone lesions. There are no established protocols for treating CRMO; thus, current practice is largely empirical. Data on the use of zoledronic acid (ZA) in juvenile CRMO are scarce. A 12-year-old male child with a history of multiple aseptic osteomylitis, affecting the chest wall, right ankle, and wrist, had no fever. Cultures and a bone biopsy ruled out infection or malignancy. The patient's condition stayed stable while taking naproxen (20 mg/kg/day) and methotrexate (10 mg/week) for 1.5 years until he experienced right elbow pain, swelling, no overlying skin erythema, and a restricted range of motion. The laboratory tests all came back normal, including white blood cell (WBC) count, erythrocyte sedimentation rate, C-reactive protein, and immunoglobin assays. The magnetic resonance imaging showed a focal lesion in the medial humeral condyle with increased signal intensity on T2 and short tau inversion recovery, mild joint effusion, and no cortical break. Thus, intravenous ZA infusion commenced at 0.0125 mg/kg initially, followed by 0.025 mg/kg 3 months later, with a marked improvement in the patient's clinical symptoms and radiological findings. Non-steroidal anti-inflammatory drugs and methotrexate were initially effective in treating our patient's condition, but a recurrence necessitated treatment modification. To the best of our knowledge, this case is the first documented instance of the use of ZA in CRMO in Iraq and Arab nations.

An Uncommon Clinical Mystery: Systemic Lupus Erythematosus Masquerading as Aseptic Meningitis in a Male Patient.

Systemic lupus erythematosus (SLE) is an intricate autoimmune disease characterized by its impact on various organ systems, presenting with a wide range of clinical manifestations such as hematologic, neuropsychiatric, mucocutaneous, serosal, musculoskeletal, immunologic, cardiac, pleuropulmonary, and renal symptoms. Although its etiology is primarily autoimmune, various triggers, such as pregnancy, certain drugs, and infections, can result in "flares" with frequent relapses. Although more common in females, SLE is not uncommon in males, with a significant proportion experiencing a high disease burden. Over the years, many treatment modalities and approaches in modern medicine have evolved to combat this disease. However, it still poses a challenge to treating physicians due to the intricate elements in its pathogenesis. Further evidence-based studies are necessary to enhance our understanding of the disease. We describe the case of a 53-year-old man who presented with a three-day history of fever and a one-day history of altered sensorium. On evaluation, he was found to have pancytopenia and acute kidney injury. He was worked up for infectious and inflammatory causes. Investigations were strongly in favor of SLE and aseptic meningitis. We started him on pulse steroid therapy, following which he had substantial recovery. After one year, he presented with complaints of frothy urine, when lupus nephritis was diagnosed, and he was started on specific immunosuppressive agents. He has had no further episodes of relapse since then.