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A 15-year-old girl presented to her pediatrician with a 2-month history of rash and joint pain. During summer vacation she developed facial rash. Initially, it was thought to be sunburn, but it persisted. Her joints felt stiff and achy. On physical exam, she had a malar rash and a painless ulcer on her hard palate. She had effusions of wrists. The rest of her physical exam was normal. Labs revealed leukopenia, an elevated ESR, and low C3 and C4. Urinalysis and CMP were normal. She had a positive ANA of 1:1280 with a positive double-stranded DNA antibody. She was referred to rheumatology and diagnosed with systemic lupus erythematosus. She was started on immunosuppressive therapy.

She initially does well and starts 10th grade, but then presents to her pediatrician 2 months later with difficulty concentrating and depressed mood. Her parents initially attribute her symptoms to stress from her new diagnosis and a demanding school workload. Normally an honor roll student, she is finding it difficult to focus on her work and her grades are falling. She seems sad and irritable. She is not interested in doing things with her friends. She admits to sometimes feeling suicidal and to hearing voices telling her to harm herself.

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Congratulations to Kevin Rodowicz, DO, of Orefield, Pennsylvania, who was first to correctly guess the answer to last issue’s challenge, disseminated Lyme disease, the topic of this issue’s cover story.