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Mohanty B, Sunder A. Lupus myocarditis-A rare case. J Family Med Prim Care 2020; 9:4441-4443. [PMID: 33110880 PMCID: PMC7586557 DOI: 10.4103/jfmpc.jfmpc_716_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/11/2020] [Accepted: 07/01/2020] [Indexed: 11/13/2022] Open
Abstract
Myocarditis in patients of systemic lupus erythematosus is extremely rare and is potentially life threatening. This may be the first presentation of the disease. Here, we report a patient who presented with features of heart failure and was later diagnosed to have SLE.
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Affiliation(s)
- Bijaya Mohanty
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Ashok Sunder
- Department of Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India
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Herath HMMTB, Kulatunga A. Systemic lupus erythematosus presenting with status epilepticus and acute cardiomyopathy with acute heart failure: case report. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020; 56:15. [PMID: 32435128 PMCID: PMC7223658 DOI: 10.1186/s41983-020-0149-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/06/2020] [Indexed: 12/29/2022] Open
Abstract
Introduction Systemic lupus erythematosus is a connective tissue disorder, which causes complex multi organ involvement. Neurological and cardiac manifestations have been well noted but complications such as status epilepticus and acute myocarditis with heart failure at presentation remains uncommon. Case description A 15-year-old, previously healthy, South Asian, Sri Lankan female presented with status epilepticus and the seizures only responded to intravenous midazolam and thiopentone sodium. On the fourth day, she developed tachycardia and shortness of breath and was found to have cardiomyopathy with heart failure with an ejection fraction 40%. Along with a positive urinary sediment, a positive ANA with a very high level of ds-DNA and low C3 and C4 levels confirmed our suspicion of systemic lupus erythematosus. Discussion and evaluation Systemic lupus erythematosus presents in a variety of clinical presentations and the spectrum may range from unique to ubiquitous. Clinicians should have a high index of suspicion specially when encountering atypical presentations with multi-organ involvement, especially when patients tend to be young females. Status epilepticus and myocarditis are uncommon manifestations of systemic lupus erythematosus, and should be appreciated early, as if inappropriately managed would have a deleterious impact on mortality and morbidity.
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3
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Al-Nokhatha SA, Khogali HI, Al Shehhi MA, Jassim IT. Myocarditis as a lupus challenge: two case reports. J Med Case Rep 2019; 13:343. [PMID: 31744544 PMCID: PMC6864968 DOI: 10.1186/s13256-019-2242-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/26/2019] [Indexed: 12/13/2022] Open
Abstract
Background Myocarditis is an uncommon manifestation of systemic lupus erythematosus in which the clinical presentation can range from subclinical to life-threatening. We report cases of two patients who presented to our hospital with myocarditis as an initial manifestation of systemic lupus erythematosus despite negative results of extensive workup that excluded other diagnoses. The mainstays of treatment are corticosteroids, immunosuppressive agents, and anti-heart failure medications, with use of the latter being case-specific. Mycophenolate mofetil was the cornerstone of the proposed treatment for induction of remission, although it is well known to be used as a maintenance therapy in lupus myocarditis. Case presentation Both Emirati patients described satisfied the diagnostic criteria for mixed connective tissue disease (systemic lupus predominant) and systemic lupus erythematous. Other differential diagnoses of myocarditis were excluded. The patients were started on pulsed steroid followed by oral steroid, with hydroxychloroquine, mycophenolate mofetil, and anti-heart failure medications used as needed. Dramatic responses were noted in the first few weeks in terms of symptoms. Conclusion Early recognition and treatment of lupus myocarditis is needed to avoid fatal consequences.
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Affiliation(s)
| | - Hiba Ibrahim Khogali
- Department of Rheumatology, Internal Medicine, Tawam Hospital, Al Ain, United Arab Emirates
| | | | - Imad Tarik Jassim
- Department of Rheumatology, Internal Medicine, Tawam Hospital, Al Ain, United Arab Emirates
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4
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Systemic Lupus Erythematosus Presenting as Myopericarditis with Acute Heart Failure: A Case Report and Literature Review. Case Rep Rheumatol 2019; 2019:6173276. [PMID: 31428503 PMCID: PMC6681595 DOI: 10.1155/2019/6173276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/07/2019] [Accepted: 07/14/2019] [Indexed: 01/31/2023] Open
Abstract
Acutely decompensated dilated cardiomyopathy in a middle-aged patient without the typical risk factor profile presents a clinical dilemma. While cardiomyopathy is a known aspect of systemic lupus erythematosus (SLE), initial clinical presentation as decompensated dilated cardiomyopathy (DCM) is exceedingly rare in the literature. We share the case of a 49-year-old African-American female with no past medical history who presented with overt heart failure of 4 weeks evolution. Workup showed acute onset decompensated dilated cardiomyopathy, with a serologic profile compatible with SLE. She responded well to immunosuppressive steroid therapy. Literature review for SLE presenting as dilated cardiomyopathy with acute heart failure revealed a paucity of clinical evidence and consensus. Therefore, a comprehensive review of case reports was undertaken. A total of 10 cases were identified. Patients were 90% female and averaged 31 years of age. Dyspnea was the most common clinical presentation, and dilated cardiomyopathy with severely compromised left ventricular function was universally appreciated. Clinical presentation to diagnosis averaged 2 weeks. Immunosuppressive therapy regimens were universally employed; however, the regimens varied significantly. High-dose steroid therapy was most commonly used, and clinical and functional recovery was reported in 90% of individual case reports. Within the limited evidence and experience of therapeutic approaches, the efficacy of different singular or combined therapy is based solely on anecdotal case reports. Given the near-complete response to a short course of high-dose steroid therapy as much in the clinical recovery as in the resolution of DCM, the limited evidence based on review of these observational case studies and series supports the initial use of high-dose steroid therapy in acute lupus myocarditis.
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Lo CH, Wei JCC, Tsai CF, Li LC, Huang SW, Su CH. Syncope caused by complete heart block and ventricular arrhythmia as early manifestation of systemic lupus erythematosus in a pregnant patient: a case report. Lupus 2018; 27:1729-1731. [PMID: 29954280 DOI: 10.1177/0961203318782425] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Systemic lupus erythematosus (SLE) can affect all heart structures including the conduction system, with either reversible or permanent derangement. However, only a few cases of adult SLE and complete atrioventricular (AV) block have been reported. We describe a young pregnant woman who initially presented with complete AV block on electrocardiography before the diagnosis of SLE. Syncope subsequently developed during the postpartum period due to frequent nonsustained polymorphic ventricular tachycardia, suggesting lupus myocarditis. The ventricular arrhythmia was successfully treated by intravenous corticosteroids, lidocaine and implantation of a permanent pacemaker. This may represent the first report of complete AV block with polymorphic ventricular tachycardia, which was identified before the other clinical features of SLE fully manifested. SLE should be considered if a patient presents with complete AV block without other clinical features. It may warn for early diagnosis and appropriate treatment of SLE including lupus-related heart disease.
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Affiliation(s)
- C H Lo
- 1 Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung City, Taiwan
| | - J C C Wei
- 2 Division of Allergy, Immunology and Rheumatology, Chung Shan Medical University Hospital; Institute of Medicine, Chung Shan Medical University; Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - C F Tsai
- 1 Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung City, Taiwan.,3 School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
| | - L C Li
- 4 Department of Internal Medicine, Da Chien General Hospital, Miao Li City, Taiwan
| | - S W Huang
- 1 Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung City, Taiwan
| | - C H Su
- 1 Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung City, Taiwan.,3 School of Medicine, Chung Shan Medical University, Taichung City, Taiwan
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6
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Manautou L, Jerjes-Sanchez C, Meraz M, Perez-Garcia LF, Diaz-Cid A, de la Peña-Almaguer E, Avila C, Sanchez L. Myopericarditis with predominantly right ventricular involvement with normal B-type natriuretic peptide and cardiac tamponade as the initial manifestation of systemic lupus erythematosus. Lupus 2014; 23:935-8. [PMID: 24704777 DOI: 10.1177/0961203314530486] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Accepted: 03/11/2014] [Indexed: 11/16/2022]
Abstract
A previously healthy young man presented with a 12-hour history of sudden dyspnea and severe chest pain at rest. Initial findings of physical examination, electrocardiogram and chest radiography showed typical pericarditis and clinical instability. Echocardiogram revealed small pericardial effusion with right ventricle dilatation. The patient was admitted in the ICU; a new echocardiogram revealed moderate pericardial effusion and diagnosis of pericarditis complicated with acute cardiac tamponade was established. The patient transiently improved after pericardial window. In the following hours, the diagnosis of myocarditis with predominantly right ventricular involvement (MPRVI) with severe right heart failure was supported by clinical, chest radiography and echocardiogram data, despite normal B-type natriuretic peptide. On day 2, cardiac troponin I detection was observed. By day 3, B-type natriuretic peptide in the range of ventricular dysfunction was identified. Cardiovascular magnetic resonance findings supported the diagnosis of MPRVI. A systematic MEDLINE/PubMed from 1993 to 2013 does not identify any cases of MPRVI related to systemic lupus erythematosus. Simultaneous acute MPRVI with normal B-type natriuretic peptide and acute cardiac tamponade heralding the diagnosis of systemic lupus erythematosus, to the best of our knowledge, has not been previously described.
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Affiliation(s)
- Luis Manautou
- Instituto de Cardiologia y Medicina Vascular, TEC Salud. Tecnologico de Monterrey, Nuevo Leon, MexicoEscuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Carlos Jerjes-Sanchez
- Instituto de Cardiologia y Medicina Vascular, TEC Salud. Tecnologico de Monterrey, Nuevo Leon, MexicoEscuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Manuel Meraz
- Instituto de Cardiologia y Medicina Vascular, TEC Salud. Tecnologico de Monterrey, Nuevo Leon, MexicoEscuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Luis F Perez-Garcia
- Instituto de Cardiologia y Medicina Vascular, TEC Salud. Tecnologico de Monterrey, Nuevo Leon, MexicoEscuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Antonio Diaz-Cid
- Instituto de Cardiologia y Medicina Vascular, TEC Salud. Tecnologico de Monterrey, Nuevo Leon, MexicoEscuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Erasmo de la Peña-Almaguer
- Instituto de Cardiologia y Medicina Vascular, TEC Salud. Tecnologico de Monterrey, Nuevo Leon, MexicoEscuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Cesar Avila
- Instituto de Cardiologia y Medicina Vascular, TEC Salud. Tecnologico de Monterrey, Nuevo Leon, MexicoEscuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Luis Sanchez
- Instituto de Cardiologia y Medicina Vascular, TEC Salud. Tecnologico de Monterrey, Nuevo Leon, MexicoEscuela de Medicina y Ciencias de la Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
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Ishimori ML, Agarwal M, Beigel R, Ng RK, Firooz N, Weisman MH, Siegel RJ. Systemic Lupus Erythematosus Cardiomyopathy-A Case Series Demonstrating a Reversible Form of Left Ventricular Dysfunction. Echocardiography 2013; 31:563-8. [DOI: 10.1111/echo.12425] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mariko L. Ishimori
- Division of Rheumatology; Cedars-Sinai Medical Center; Los Angeles California
| | - Megha Agarwal
- The Heart Institute; Cedars Sinai Medical Center; Los Angeles California
| | - Roy Beigel
- The Heart Institute; Cedars Sinai Medical Center; Los Angeles California
| | - Rita K. Ng
- The Heart Institute; Cedars Sinai Medical Center; Los Angeles California
| | - Nazanin Firooz
- Division of Rheumatology; Cedars-Sinai Medical Center; Los Angeles California
| | - Michael H. Weisman
- Division of Rheumatology; Cedars-Sinai Medical Center; Los Angeles California
| | - Robert J. Siegel
- The Heart Institute; Cedars Sinai Medical Center; Los Angeles California
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Luijten RK, Fritsch-Stork RD, Bijlsma JW, Derksen RH. The use of glucocorticoids in Systemic Lupus Erythematosus. After 60years still more an art than science. Autoimmun Rev 2013; 12:617-28. [DOI: 10.1016/j.autrev.2012.12.001] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 12/02/2012] [Indexed: 01/18/2023]
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Baquero G, Banchs JE, Naccarelli GV, Gonzalez M, Wolbrette DL. Cardiogenic shock as the initial presentation of systemic lupus erythematosus: a case report and review of the literature. ACTA ACUST UNITED AC 2012; 18:337-41. [PMID: 22507209 DOI: 10.1111/j.1751-7133.2011.00283.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Giselle Baquero
- Department of Medicine & Heart and Vascular Institute, Penn State Hershey College of Medicine, PA, USA.
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10
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Hall D, New D, Kelly T. Postpartum dilated cardiomyopathy in a patient with systemic lupus erythematosus, nephritis and lupus anticoagulant: a diagnostic dilemma. Obstet Med 2011; 4:117-9. [PMID: 27579105 DOI: 10.1258/om.2011.100063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2011] [Indexed: 11/18/2022] Open
Abstract
A 32-year-old Caucasian woman presented with shortness of breath four weeks postpartum. She was known to suffer from systemic lupus erythematosus with cutaneous, joint and minor renal involvement. During pregnancy, the patient had developed nephrotic syndrome for which she was managed with prophylactic anticoagulation and corticosteroid therapy. A leg deep vein thrombosis had arisen following caesarean section following antepartum haemorrhage. Examination revealed a heart murmur, and pulmonary signs. Computed tomography pulmonary angiogram showed cardiomegaly and bilateral pleural effusions but no pulmonary embolus. Echocardiogram demonstrated dilated cardiomyopathy. An initial diagnosis of peripartum cardiomyopathy was considered, with lupus myocarditis and coronary in situ thrombosis among the differential diagnoses.
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Affiliation(s)
- Daniel Hall
- University of Manchester Medical School , Manchester , UK
| | - David New
- Salford Royal Foundation Trust , Greater Manchester , UK
| | - Teresa Kelly
- Salford Royal Foundation Trust , Greater Manchester , UK
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Gurjar M, Singhal S, Poddar B, Baronia AK, Azim A. Acute cardiogenic shock in a girl with systemic lupus erythematosus. Indian J Crit Care Med 2011; 14:209-11. [PMID: 21572754 PMCID: PMC3085224 DOI: 10.4103/0972-5229.76087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Cardiac involvement is one of the main complications substantially contributing to the morbidity and mortality of patients suffering from systemic lupus erythematous (SLE). However, clinically important myocarditis is an unusual feature in SLE. We describe the clinical characteristics, management, and outcome of a 15-year young girl with SLE who developed severe left ventricular dysfunction.
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Affiliation(s)
- Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow-226 014, UP, India
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12
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Carvalheiras G, Anjo D, Mendonça T, Vasconcelos C, Farinha F. Hemophagocytic syndrome as one of the main primary manifestations in acute systemic lupus erythematosus - case report and literature review. Lupus 2009; 19:756-61. [DOI: 10.1177/0961203309354906] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemophagocytic syndrome is an unusual but fatal disorder characterized by pancytopenia and activation of macrophages. We describe one case of acute systemic lupus erythematosus with an unusual presentation of hemophagocytic syndrome not related to infection. The patient presented with pancytopenia related to increasing hemophagocytic activity of histiocytes in the bone marrow. Concomitant class IV World Health Organization lupus nephritis, serositis, high titer of antinuclear factor and positive test for anti-DNA antibody fitted the diagnostic criteria of systemic lupus erythematosus. She also presented with alveolar hemorrhage and lupus myocarditis. She underwent immunosuppressive therapy with recovery from the hemophagocytic syndrome. Therefore, diagnosis of acute lupus hemophagocytic syndrome was made. The clinical presentation, laboratory diagnosis, and management of the patient are discussed and the literature was reviewed and presented, with emphasis on a possible distinct lupus subset, which includes a more aggressive systemic disease with heart involvement.
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Affiliation(s)
- G. Carvalheiras
- Internal Medicine, Centro Hospitalar do Porto, Hospital Santo António, Porto, Portugal,
| | - D. Anjo
- Cardiology, Centro Hospitalar do Porto, Hospital Santo António, Porto, Portugal
| | - T. Mendonça
- Internal Medicine, Centro Hospitalar do Porto, Hospital Santo António, Porto, Portugal, Clinic Immunology, Centro Hospitalar do Porto-Hospital de Santo Antonio, Porto, Portugal
| | - C. Vasconcelos
- Internal Medicine, Centro Hospitalar do Porto, Hospital Santo António, Porto, Portugal, Clinic Immunology, Centro Hospitalar do Porto-Hospital de Santo Antonio, Porto, Portugal
| | - F. Farinha
- Internal Medicine, Centro Hospitalar do Porto, Hospital Santo António, Porto, Portugal, Clinic Immunology, Centro Hospitalar do Porto-Hospital de Santo Antonio, Porto, Portugal
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