Other manifestations of CNS involvement, such as psychosis, also may need inpatient evaluation Listeria monocytogenes may cause indolent meningitis that is clinically indistinguishable from organic brain syndromes Similarly, it may be difficult to determine whether psychosis is secondary to corticosteroid therapy; steroids are most likely to induce an altered sensorium in patients with underlying psychiatric disease Clinicians should aggressively pursue a diagnostic evaluation, including lumbar puncture and imaging procedures, so appropriate therapy may be instituted as expeditiously as possible When psychosis due to SLE is suspected, psychotropic drugs (e.g., haloperidol 0.025 to 0.05 mg/kg/day in divided doses) may be used along with large doses of corticosteroids for to weeks If there is no improvement, the steroid dose may be reduced gradually in an attempt to rule out steroid-induced psychosis Transverse myelitis is a rare complication of SLE believed to result from vascular compromise of the spinal cord Patients note acute onset of pain and weakness, and they may develop incontinence Physical examination is remarkable for weakness or flaccid paralysis below the level of the functional transection In a high percentage of cases, the process is associated with a circulating lupus anticoagulant or antiphospholipid antibodies Prognosis is related to the duration of symptoms prior to initiation of therapy, and favorable outcomes are only possible with urgent intervention Thus, once infection and hematoma are excluded with appropriate imaging procedures and lumbar puncture, pulse doses of IV methylprednisolone (30 mg/kg over to hours), anticoagulation with IV heparin, and other immunosuppressive agents should be administered Pulmonary Complications Pleural effusion is the most common pulmonary manifestation of SLE Pleural effusion is often bilateral and small, although occasionally it may be massive The child is often ill with acute manifestations of systemic disease, such as fever, fatigue, and poor appetite Symptoms may be minimal or absent; in the presence of a moderate or large effusion, the patient may have dyspnea and tachypnea If the child has a previous history of pleurisy and there are no concerns about infection, outpatient management may be possible for small pleural effusions Increasing the corticosteroid dose or adding an NSAID such as indomethacin (0.5 to mg/kg/day) may be adequate therapy, but arrangements must be made for close followup Thoracentesis is often necessary (i) to relieve symptoms, (ii) for diagnosis, or (iii) to reveal any underlying lesions obscured by the effusion Pleural effusions caused by SLE usually are exudative, with elevated protein levels and cell counts, primarily neutrophils early and lymphocytes later, with normal glucose and the presence of ANAs Pulmonary hemorrhage is a potentially catastrophic complication of SLE, particularly in the pediatric age group Early recognition and treatment are critical A hemorrhage may be related to the disease itself (e.g., pulmonary vasculitis), to the