Cardiac involvement in systemic lupus erythematosus

Echocardiography in Systemic Lupus Erythematosus

PURPOSE OF REVIEW

In patients with systemic lupus erythematosus (SLE), cardiovascular involvement is common and a major cause of morbidity and mortality. There have been few recent updates regarding the cardiac involvement in this clinical entity. The purpose of the review is to provide an update on the role of echocardiography in the management of these patients.

RECENT FINDINGS

Echocardiography remains the imaging modality of choice and should be considered even in asymptomatic patients with SLE to detect cardiac abnormalities which are frequently not clinically apparent. Transesophageal echocardiography has higher sensitivity and specificity in identifying valvular lesions, and should be utilized in high risk patients when transthoracic echocardiography is negative. New advances such as speckle tracking echocardiography has shown promise in the detection of occult myocardial dysfunction, but more studies are needed to have a proper perspective of its role in SLE patients. SLE has protean cardiac manifestations. The most common involvement is pericarditis. Complicated pericarditis such as tamponade and constriction are rare but should be considered if the symptoms do not subside with treatment. Valvular involvement can take several forms. Libman-Sacks endocarditis is the most common form and is more prevalent in patients with high disease activity and with the presence of antisphopholipid antibodies. Myocardial involvement portends poor prognosis and should be sought and treated promptly to prevent morbidity and mortality.

A case report of systemic lupus erythematosus complicating interstitial lung disease and thickened pericardium treated with tofacitinib

RATIONALE

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that damages multiple organs and systems, including the lungs, kidneys, and heart. The respiratory system is commonly affected by SLE, leading to problems such as pleurisy, pleural effusion, and interstitial lung disease (ILD). In addition, SLE can involve the heart, with pericarditis being the most common manifestation. Notably, pericardial effusion frequently accompanies pericarditis involved by SLE, and aspects such as thickened pericardium (TP) can be challenging to detect early on. There are limited reports on TP and even fewer reports on the treatment of ILD with TP. This study investigates the clinical treatment of SLE complicating ILD and TP and reports on a successful case treated with tofacitinib, offering new strategies for managing such patients.

PATIENT CONCERNS

A 35-year-old female patient presented to the hospital with polyarticular swelling and pain that had been ongoing for over 4 years, as well as recurrent chest pain for 2 years that worsened over the course of 1 day.

DIAGNOSES

The patient was diagnosed with SLE complicating ILD and TP, with hematologic involvement.

INTERVENTIONS

Treatment involved the administration of tofacitinib in combination with low-dose methylprednisolone (MP) and mycophenolate mofetil (MMF).

OUTCOMES

The patient experienced recurrent chest pain and difficulty in reducing glucocorticoids (GCs), but the patient conditions were improved upon the addition of tofacitinib. The patient has been followed up for 16 months, and the patient MP dosage has been reduced to 6 mg once daily. The patient condition remains stable without recurrence, and the patient quality of life has improved.

LESSONS

In cases of SLE complicating ILD and TP, when tapering GCs is difficult, treatment with tofacitinib can be effective in achieving remission and maintaining stability.

Three-dimensional speckle tracking echocardiography for evaluation of ventricular function in patients with systemic lupus erythematosus: relationship between duration of lupus erythematosus and left ventricular dysfunction by using global longitudinal strain

BACKGROUND

Cardiovascular diseases are leading causes of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Cardiac involvement in SLE can often go undetected. Three-dimensional (3D) speckle tracking echocardiography (STE) is a noninvasive imaging technique that can assess the function of the heart's ventricles in an accurate and reproducible way. This makes it an attractive option for detecting early signs of heart disease in SLE patients. By identifying these subclinical cardiac abnormalities, 3D-STE may help reduce the negative impact of cardiovascular diseases in SLE population. Therefore, this study aimed to compare the left ventricular (LV) function between patients with SLE compared to age- and gender-matched controls using two-dimensional (2D) and 3D-STE.

RESULTS

The current study found no significant differences in left ventricle ejection fraction, left ventricle end-diastolic volume, left ventricle end-systolic volume, left ventricle end-diastolic mass, and left ventricle end-systolic mass between the two groups. However, the SLE group exhibited a significantly lower LV global longitudinal strain (GLS) compared to the control group according to all types of echocardiographic assessments, including 3D and 2D long-axis strain, apical 2-chamber, and apical 4-chamber assessments (all P values < 0.05). Furthermore, a good inter-rater reliability and intra-rater reliability were observed regarding the LVGLS measurement with 3D-STE. Additionally, the study identified a significant correlation between LVGLS and SLE duration (r (50) = 0.46, P < 0.001). The use of prednisolone and nephrology disorders was also found to impact LVGLS measurements.

CONCLUSIONS

Despite a normal LVEF in patients with SLE, LVGLS measurements indicated that LV systolic dysfunction was observed more frequently in SLE patients compared to their healthy counterparts. Therefore, advanced 3D-STE techniques may be useful in identifying subtle abnormalities in LV function in SLE patients.

Low estimated glomerular filtration rate and high body mass index are risk factors for acute kidney injury in systemic lupus erythematosus patients after cardiac surgery

Objective

The occurrence of acute kidney injury (AKI) is common following cardiac surgery, especially among patients characterized with systemic lupus erythematosus (SLE), but studies on this clinical scenario have been limited by the rarity of SLE. We aimed to explore the risk predictors and outcomes with regards to postoperative AKI among cardiac-surgical patients concomitant with SLE.

Methods

This was a single-center retrospective study performed in a tertiary hospital. Adult patients diagnosed with SLE who underwent cardiac surgery within the last 22 years were enrolled. Essential variables, including patient-, surgery- and anesthesia-related information, were collected from the medical record system. The definition of AKI was derived from the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Risk predictors suspected to be linked with post-surgical AKI were calculated using the univariable and multivariable analyses.

Results

Of all 59 SLE patients undergoing cardiac surgery, 57 were ultimately enrolled into the analysis. AKI occurred in 29 patients (50.9%), who had significantly longer extubation time (median difference 1.0 day, P < 0.001), ICU length of stay (median difference 2.0 days, P = 0.001), postoperative length of stay (median difference 5.0 days, P = 0.026), and more postoperative major complications (odds ratio 10.29, P = 0.025) than the others. Preoperative estimated glomerular filtration rate (eGFR) < 60 ml/min/1.73 m2 (odds ratio 5.31, P = 0.021) and body mass index (BMI) ≥ 24 kg/m2 (odds ratio 4.32, P = 0.043) were the only two factors in the multivariable analysis that were significantly correlated with the development of postoperative AKI in patients with SLE after cardiac surgery.

Conclusion

AKI in SLE patients after cardiac surgery is common and requires scrutiny, especially in overweight patients with moderate to severe preoperative renal dysfunction.

Hypertrophic Cardiomyopathy Requiring Myectomy in a Young Patient With Systemic Lupus Erythematosus: A Case Report

Systemic lupus erythematosus (SLE) is an autoimmune disease that can affect multiple organ systems. Among these, the heart, including the pericardium, conduction system, myocardium, valves, and coronary arteries, can be affected. Hypertrophic cardiomyopathy (HCM) is a myocardial disease caused mainly by genetic mutation. The association between SLE and HCM is still unclear. We are reporting a case of a 25-year-old female with SLE with end-stage renal disease (ESRD) due to lupus nephritis, who was found to have hypertrophic obstructive cardiomyopathy (HOCM) on the echocardiogram and required septal myectomy. She presented to the hospital with dyspnea and was admitted as a hypertensive emergency with pulmonary edema, which required intubation and admission to the cardiac intensive care unit (CICU). She underwent urgent hemodialysis and blood pressure medication adjustment and then improved and was discharged home. Based on the literature review, 10 cases of SLE and HCM were reported, and the underlying mechanisms linking SLE and HCM remain unclear. Further studies are warranted for a better understanding of the association between SLE and HCM.

Two-dimensional speckle-tracking echocardiography in left ventricular systolic function in patients with systemic lupus erythematosus

OBJECTIVES

To investigate whether two-dimensional speckle-tracking echocardiography (2DSTE) can be considered a criterion for early left ventricular (LV) systolic impairment in patients with systemic lupus erythematosus (SLE) and to further explore the association with each other.

METHODS

We included 38 patients with SLE and assessed the degree of disease activity according to the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) 2000 scoring criteria, together with 38 healthy controls who were matched by sex and age. Routine LV systolic function evaluation parameters were obtained by echocardiography as well as 2DSTE measurement of LV strain parameters to obtain global longitudinal strain (GLS) values, respectively.

RESULTS

(I) On routine LV function parameters such as ejection fractions (EF) and left ventricular end-diastolic internal diameter (LVIDd), the SLE group and the control group did not reflect differences. In contrast, on the LV strain parameter obtained from 2DSTE measurements, the GLS values in all cardiac planes were lower in the SLE group than in the control group and showed statistically significant differences. (II) Correlation analysis showed that there was a correlation between SLEDAI and GLS, especially a meaningful correlation with GLS Avg and GLS A4C, with correlation coefficients of 0.35 and 0.47, respectively.

CONCLUSIONS

The use of 2DSTE can detect early impaired LV systolic function in SLE patients, and GLS is progressively gaining attention as an indicator of subclinical myocardial injury and LV function in SLE patients. The correlation that exists between GLS and SLEDAI might contribute to a better assessment of cardiac involvement in SLE patients. Key Points • Cardiac involvement has become one of the major factors in the poor prognosis of SLE patients, which directly affects the mortality of SLE patients. Traditional echocardiography is difficult to detect early left ventricular function impairment, thus affecting clinicians' judgment and diagnosis. • 2DSTE can recognize subclinical myocardial injury in SLE patients at an early stage, and its derived strain parameters may be used as an indicator to evaluate myocardial involvement and reflect disease activity in SLE patients.

Myocarditis and Chronic Inflammatory Cardiomyopathy, from Acute Inflammation to Chronic Inflammatory Damage: An Update on Pathophysiology and Diagnosis

Acute myocarditis covers a wide spectrum of clinical presentations, from uncomplicated myocarditis to severe forms complicated by hemodynamic instability and ventricular arrhythmias; however, all these forms are characterized by acute myocardial inflammation. The term "chronic inflammatory cardiomyopathy" describes a persistent/chronic inflammatory condition with a clinical phenotype of dilated and/or hypokinetic cardiomyopathy associated with symptoms of heart failure and increased risk for arrhythmias. A continuum can be identified between these two conditions. The importance of early diagnosis has grown markedly in the contemporary era with various diagnostic tools available. While cardiac magnetic resonance (CMR) is valid for diagnosis and follow-up, endomyocardial biopsy (EMB) should be considered as a first-line diagnostic modality in all unexplained acute cardiomyopathies complicated by hemodynamic instability and ventricular arrhythmias, considering the local expertise. Genetic counseling should be recommended in those cases where a genotype-phenotype association is suspected, as this has significant implications for patients' and their family members' prognoses. Recognition of the pathophysiological pathway and clinical "red flags" and an early diagnosis may help us understand mechanisms of progression, tailor long-term preventive and therapeutic strategies for this complex disease, and ultimately improve clinical outcomes.

Cardiac Abnormalities in Relation to the Disease Activity Index Among Systemic Lupus Erythematosus Patients in a Tertiary Hospital: A Cross-Sectional Study

BACKGROUND

 Systemic lupus erythematosus (SLE) is a multisystem autoimmune connective tissue disorder involving multiple organs and systems. Cardiovascular involvement in SLE patients is a major cause of morbidity and mortality. Although subclinical cardiac abnormalities exist among SLE patients, they are rarely screened for. Echocardiography has been demonstrated to be a useful tool for the early diagnosis of cardiac abnormalities in SLE patients, many of which are clinically silent. Early recognition of cardiovascular abnormalities is vital for the prompt initiation of the appropriate management. This study aims to determine the prevalence of various structural and functional cardiac abnormalities among SLE patients and to determine its association with the modified SLE Disease Activity Index 2000 (modified SLEDAI-2K).

METHODS

 The study was a cross-sectional study of SLE patients at the Korle-Bu Teaching Hospital (KBTH), Accra, Ghana, from June to December 2021. The setting was the rheumatology outpatient clinic of the KBTH and included adult men and women, 18 years and above, diagnosed with SLE with no known cardiac abnormalities. The baseline demographic and clinical characteristics of the participants were determined. A detailed transthoracic echocardiogram was performed for all patients. The frequency of common cardiac pathologies was determined and compared between those with a high modified SLEDAI-2K and those with a low modified SLEDAI-2K.

RESULTS

 Ninety-nine SLE patients participated in the study with a mean age of 35.12 years. Females formed the majority (90.9%) of the participants. The mean age at diagnosis of SLE was 28.7 years and the mean disease duration was 4.6 years. All of the participants were on at least two disease-modifying medications. The mean modified SLEDAI-2K score was 9.1. Thirty-five percent (35%) of the patients had mild to moderately active disease and 39% had severely active disease. Sixty-six (66%) out of the severely active disease group had abnormal echocardiographic findings, while 28% of those with mild to moderate disease had abnormal echocardiographic findings. Echocardiographic abnormalities were found in 56 patients (47%), out of which 8.7% had valvular involvement, 15.7% had diastolic dysfunction, 5.2% had left ventricular hypertrophy (LVH), and 0.9% had left ventricular systolic dysfunction (LVSD). About 12% of the participants had pulmonary hypertension and 1% had pericardial involvement. The odds of echocardiographic abnormalities were 13.7 times higher in SLE patients with high disease activity compared to those with low disease activity (odds ratio (OR) = 13.714, 95% confidence interval (CI) = 3.804-49.442, p < 0.001). There was no significant association between cardiac abnormalities and SLE duration. No significant correlation between cardiac abnormalities and modified SLEDAI-2K score was found.  Conclusion: Cardiac abnormalities, especially left ventricular diastolic dysfunction (LVDD), valvular involvement, and pulmonary hypertension, are common in SLE patients. For SLE patients, especially those with active diseases, echocardiographic assessment should be considered in the management of SLE patients to enable early detection of cardiac abnormalities, early treatment, and thus a decrease in morbidity and mortality associated with cardiovascular involvement in SLE patients.

Cardiac magnetic resonance assessment of cardiac involvement in autoimmune diseases

Cardiac magnetic resonance (CMR) is emerging as the modality of choice to assess early cardiovascular involvement in patients with autoimmune rheumatic diseases (ARDs) that often has a silent presentation and may lead to changes in management. Besides being reproducible and accurate for functional and volumetric assessment, the strength of CMR is its unique ability to perform myocardial tissue characterization that allows the identification of inflammation, edema, and fibrosis. Several CMR biomarkers may provide prognostic information on the severity and progression of cardiovascular involvement in patients with ARDs. In addition, CMR may add value in assessing treatment response and identification of cardiotoxicity related to therapy with immunomodulators that are commonly used to treat these conditions. In this review, we aim to discuss the following objectives: •Illustrate imaging findings of multi-parametric CMR approach in the diagnosis of cardiovascular involvement in various ARDs;•Review the CMR signatures for risk stratification, prognostication, and guiding treatment strategies in ARDs;•Describe the utility of routine and advanced CMR sequences in identifying cardiotoxicity related to immunomodulators and disease-modifying agents in ARDs;•Discuss the limitations of CMR, recent advances, current research gaps, and potential future developments in the field.

A 35-Year-Old Female With a Lupus Flare Presenting as Cardiac Tamponade: A Case Report

Systemic lupus erythematosus (SLE) is a chronic autoimmune disorder that affects multiple organ systems, significantly impacting the cardiovascular system. One potential complication of acute SLE flare is the development of pericardial effusion which can lead to potentially life-threatening consequences if not promptly identified. In this report, we describe the case of a 35-year-old female with a known history of SLE who developed rapid-onset, large-volume pericardial effusion with tamponade during a lupus flare. She received emergency treatment involving pericardiocentesis and was administered high doses of glucocorticoid and immunosuppressive medication. As a result, the pericardial effusion gradually resolved, and the patient's symptoms improved. This case emphasizes the significance of immediately identifying and managing swiftly progressing pericardial effusion in SLE patients. This is crucial as it can lead to severe and potentially lethal complications.

Effusive-constrictive pericarditis as first manifestation of late-onset systemic lupus erythematosus: an atypical case with grave prognosis

BACKGROUND

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that has a great diversity of clinical presentations and occurs mostly in young women. However, late-onset SLE does exist and seldom presents with an atypical case, including pericardial effusion (PE).

CASE PRESENTATION

A 64 years old Asian woman presented with weakness all over the body and slight breathlessness for the past 2 days before the hospital admission. Her initial vital signs are 80/50 mmHg for blood pressure and a respiration rate of 24 breaths/min. Rhonchi were heard on the left lung and pitting edema on both legs. No evidence of any skin rash. Laboratory examination displayed anemia, hematocrit decrement, and azotemia. A 12-lead ECG demonstrated left-axis deviation with low voltage (Fig. 1). Chest X-ray showed left massive pleural effusion (Fig. 2). Transthoracic echocardiography revealed biatrial enlargement, normal EF 60%, diastolic dysfunction grade II, and thickening of the pericardium with mild circumferential PE corresponding with effusive-constrictive pericarditis (Fig. 3). The patient also brought CT angiography and cardiac MRI result, which confirmed pericarditis with PE. Treatment was initiated in ICU with fluid resuscitation of normal saline. The patient's routine oral treatments, including furosemide, ramipril, colchicine, and bisoprolol, were carried on. An autoimmune workup was performed by a cardiologist and demonstrated an elevation in antinuclear antibody/ANA (IF) of 1:100, which finally unveiled a diagnosis of SLE. Pericardial effusion is one critical condition to consider, despite it being an uncommon presentation in late-onset SLE. Mild pericarditis in an SLE case can be treated with corticosteroid administration. Colchicine also has been found to reduce the risk of pericarditis recurrence. However, an atypical presentation from this case led to a slightly delayed treatment that escalated the morbidity and mortality risk. The patient had a sudden cardiac arrest and passed away 3 days after being treated. Fig. 1 Initial electrocardiogram demonstrated left-axis deviation, low voltage QRS complex and T-wave inversion on lead V1-V3 Fig. 2 Chest radiograph showed left massive pleural effusion Fig. 3 Transthoracic echocardiogram displayed increased left ventricular filling pressure with diastolic dysfunction grade III, mild circumferential pericardial effusion with adjacent pleural effusion CONCLUSIONS: Atypical presentation during late-onset SLE, mainly in the form of pericardial effusion even constrictive pericarditis, should be taken into a consideration since they are a scarce feature in SLE patients. Swift recognition and prompt treatment are important for the optimal outcome.

Multimodality Cardiac Imaging in Patients with Systemic Lupus Erythematosus

Systemic lupus erythematous (SLE) is an autoimmune disease with a wide range of cardiovascular complications. The main manifestations include diseases of the coronary arteries, valves, pericardium, and myocardium. Multimodality cardiovascular imaging techniques are critical for evaluating the extent of cardiac manifestations in SLE patients, which can provide valuable prognostic information. However, their utility has previously not been well defined. This review provides a state-of-the-art update on the cardiovascular manifestations of lupus, as well as the role of multimodality cardiac imaging in guiding management of patients with SLE.

Heart Failure in Rheumatic Disease: Secular Trends and Novel Insights

There is a significant increase in risk of heart failure in several rheumatic diseases. Common cardiovascular risk factors and inflammatory processes, present in both rheumatic diseases and heart failure, are contributing to this increase. The opportunities for using immune-based strategies to fight development of heart failure in rheumatic diseases are evolving. The diversity of inflammation calls for a tailored characterization of inflammation, enabling differentiation of inflammation and subsequent introduction of precision medicine using target-specific strategies and immunomodulatory therapy. As the field of rheuma-cardiology is still evolving, clear recommendations cannot be given yet.

Severe Libman-Sacks endocarditis complicating antiphospholipid syndrome: a retrospective analysis of 23 operated cases

OBJECTIVE

Data on severe heart valve disease (HVD), including Libman-Sacks endocarditis, associated with SLE and/or APS requiring valvular surgery are scarce. We thus conducted a retrospective study, aimed at describing and clarifying clinical, laboratory, echocardiographic, histopathological and evolutional features of SLE and/or APS patients with severe associated-HVD.

METHODS

An observational retrospective multicentric analysis of 23 adults with SLE and/or APS and HVD between 1996 and 2019 and available histopathological report evaluating long-term follow-up.

RESULTS

Twenty-three individuals (20 females, median age 37 [range 17-76] years) were included. All had APS (thrombotic in 22, with an arterial phenotype in 15 and with catastrophic APS [CAPS] in six), and 11 (47%) had SLE. Systemic underlying disease had been diagnosed prior to HVD in 12 (52%). In 10 patients (43%), HVD was complicated by cerebral stroke prior to surgery. Twenty patients (87%) had only one pathological valve, the mitral valve in 18 patients (78%). Valvular thickening (n = 19) and valvular regurgitation (n = 19) were the most frequently reported lesions. Fifteen (62%) patients underwent mechanical valve replacement, six (26%) conservative valve repair (five were later re-operated after a median time of 1 [0-4] year), and two (9%) underwent biological valve replacement. Nine patients (39%) presented early-onset post-operative complications, including three CAPS immediately after surgery and one death. After surgery, 18 patients (78%) had normal postoperative valvular function, but almost half of the patients (43%) had post-operative neurological sequelae (median follow-up of 6 [2-20] years).

CONCLUSION

Severe HVD leading to surgery was strongly associated with thrombotic APS, especially arterial phenotypes. Half of the reported patients presented cerebral stroke complicating the HVD. Valvular surgery carried a significant risk of CAPS.

At the Heart of the Diagnosis: A Case of Systemic Lupus Erythematosus Presenting as Cardiac Tamponade

Systemic lupus erythematosus (SLE) is a heterogenous, systemic disease characterized by the production of pathogenic autoantibodies against nuclear antigens. Although the most common cardiac manifestation of SLE is pericardial effusions, their progression to cardiac tamponade is rare and has an incidence between 1-3%. We describe a case of a 42-year-old Hispanic woman who presented with severe shortness of breath, vague chest pain, and hemodynamic compromise secondary to cardiac tamponade. The patient's underlying etiology of cardiac tamponade was attributed to a new diagnosis of SLE based on the 2019 European Alliance of Associations for Rheumatology/American College of Rheumatology classification (EULAR/ACR) criteria for SLE. The patient's treatment consisted of a pericardial window and immunosuppressive therapy with corticosteroids, Mycophenolate, and hydroxychloroquine. This case aims to increase awareness of SLE as a possible differential diagnosis of cardiac tamponade in the appropriate clinical setting.

Autoimmune Pericarditis: Multimodality Imaging

PURPOSE OF THE REVIEW

The purpose of this review is to understand the underlying mechanism that leads to pericarditis in systemic autoimmune and autoinflammatory diseases. The underlying mechanism plays a vital role in the appropriate management of patients. In addition, we will review the current landscape of available cardiac imaging modalities with emphasis on pericardial conditions as well as proposed treatment and management tailored toward pericardial autoimmune and autoinflammatory processes.

RECENT FINDINGS

Approximately 22% of all cases of pericarditis with a known etiology are caused by systemic autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and vasculitis. In recent years, there have been advancements of imaging modalities including cardiac MRI, cardiac CT scan, and PET scan and their respective nuances in regard to contrast use, technique, and views which clinicians may utilize to better understand the extent of a patient's pericardial pathology and the trajectory of his or her disease process. In this review, we will discuss systemic autoimmune and autoinflammatory diseases that involve the pericardium. We will also review different imaging modalities that are currently used to further characterize such conditions. Having a deeper understanding of such techniques will improve patient outcomes by helping clinicians tailor treatment plans according to the unique underlying condition.

Autoimmune Rheumatic Disease Flares with Myocarditis Following COVID-19 mRNA Vaccination: A Case-Based Review

Since the introduction of coronavirus disease 2019 (COVID-19) messenger ribonucleic acid (mRNA) vaccines, there have been multiple reports of post-vaccination myocarditis (mainly affecting young healthy males). We report on four patients with active autoimmune rheumatic diseases (ARDs) and probable or confirmed myocarditis following COVID-19 mRNA vaccination managed at a tertiary hospital in Singapore; we reviewed the literature on post-COVID-19 mRNA vaccination-related myocarditis and ARD flares. Three patients had existing ARD flares (two had systemic lupus erythematosus (SLE), one had eosinophilic granulomatosis polyangiitis (EGPA)), and one had new-onset EGPA. All patients recovered well after receiving immunosuppressants comprising high-dose glucocorticoids, cyclophosphamide, and rituximab. Thus far, only one case of active SLE with myocarditis has been reported post-COVID-19 mRNA vaccination in the literature. In contrast to isolated post-COVID-19 mRNA vaccination myocarditis, our older-aged patients had myocarditis associated with ARD flares post-COVID-19 vaccination (that occurred after one dose of an mRNA vaccine), associated with other features of ARD flares, and required increased immunosuppression to achieve myocarditis resolution. This case series serves to highlight the differences in clinical and therapeutic aspects in ARD patients, heighten the vigilance of rheumatologists for this development, and encourage the adoption of risk reduction strategies in this vulnerable population.

Exploring the Risk Factors for Poor Survival in Lupus Pericarditis Patients: A Retrospective Cohort Study

Patients with systemic lupus erythematosus (SLE) have a higher risk of pericarditis, which could be fatal. The goal of this study was to identify the prognostic factors for mortality in patients with lupus pericarditis. Patients with lupus pericarditis treated at Chang Gung Memorial Hospital were included in this observational cohort study. This study conducted univariate and multivariate COX regression, as well as Kaplan−Meier survival curve analysis, to investigate mortality risk in SLE patients. The average age at admission was 40.78 ± 15.92 years. A total of 113 (16.4%) of the 689 patients had lupus pericarditis. Patients with lupus pericarditis exhibited older age, shorter follow-up, higher disease activities, and higher incidence rates of comorbidities than patients without pericarditis. Cox regression adjusted analysis indicated that lupus pericarditis (hazard ratio = 1.963, 95% CI = 1.315, 2.963, p = 0.001), old age at admission (HR = 1.053, 95% CI = 1.040, 1.065, p < 0.001), high SLEDAI score (HR = 1.079, 95% CI = 1.043, 1.116, p < 0.001), and end-stage kidney disease (ESKD) (HR = 2.533, 95% CI = 1.620, 3.961, p < 0.001) were all linked to increased mortality. Moreover, the Kaplan−Meier survival curve analysis revealed that patients with pericarditis compared to those without pericarditis had a higher mortality rate (log-rank test, p < 0.001). A high proportion of SLE patients have manifestations of lupus pericarditis. Moreover, patients with lupus pericarditis have a greater risk of mortality even if they have no pericardial tamponade. Therefore, these patients need prompt diagnosis and treatment.

Neuropsychiatric Lupus and Lupus Nephritis Successfully Treated with Combined IVIG and Rituximab: An Alternative to Standard of Care

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with unpredictable course and flares. The clinical manifestation can vary from mild to severe and life-threatening disease. Infection is the primary cause of mortality in hospitalized SLE patients. There is a paucity of evidence to support the co-management of SLE with major organ involvement and sepsis. We describe the clinical response of a 35-year-old male diagnosed with SLE; then, he developed severe sepsis and a flare of SLE with major organ involvement including lupus nephritis (LN), myocarditis, and neuropsychiatric systemic lupus erythematosus (NPSLE). Based on the patient’s condition, a treatment dilemma was encountered, and after a multidisciplinary meeting, the decision was made to use a combination of rituximab (RTX), intravenous immunoglobulin (IVIG), and pulse steroid. Shortly, the patient’s condition started to improve, and his symptoms were resolved. In conclusion, our clinical case suggests that combined RTX, IVIG, and pulse steroid seem to be effective and safe in achieving clinical response, thus representing a good choice for managing severe SLE flares in sepsis.

Mycophenolate Mofetil Use in Severe Myocarditis Complicating Systemic Lupus

Cardiac involvement represents an increasingly frequent complication in systemic lupus, with pericarditis being the most classic cardiac manifestation. However, the most severe and fatal form seems to be myocarditis. We present the case of a patient with systemic lupus complicated by cardiogenic shock secondary to troponin-negative acute myopericarditis and successfully treated with mycophenolate mofetil and corticosteroid therapy. A 33-year-old woman with no past medical history presented with asthenia and inflammatory arthralgia. She was admitted in June 2021 for acute heart failure. Transthoracic cardiac ultrasound showed dilated cardiomyopathy with global hypokinesis (20-25% of ejection fraction) and right ventricular dysfunction without significant mitral and aortic valve disease. She had raised proBNP (pro-brain natriuretic peptide), low troponin, normochromic normocytic anemia at 10.4 g/dL, positive direct Coombs, lymphopenia at 460/mm3, serum creatinine at 23.9 mg/L, and proteinuria/creatininuria 2.48 g/g. Cardiac magnetic resonance imaging (CMR) suggested the diagnosis of myopericarditis. The etiological assessment did not identify an infectious, toxic, or medicinal cause. The clinical picture suggested the possibility of an autoimmune disease. The patient presented with lesions suggestive of cutaneous vasculitis, with oral ulcers with polyarthritis. The autoimmune workup showed anti-nuclear antibodies at 1:1,280, anti-native DNA antibodies at 210 IU/mL (normal < 10 IU/mL), and positive anti-SM Abs. The diagnosis of lupus myopericarditis complicated by cardiogenic shock was made, which was associated with acute renal impairment. The patient was initiated on heart failure medications along with corticosteroids and mycophenolate mofetil. On day 15, the left ventricular ejection fraction improved to 45-50%, with clinical improvement in signs of heart failure and general condition. The existence of myopericarditis without obvious etiology, especially when there are extra-cardiac signs such as skin and joint involvement, should lead us to look for systemic lupus in order to start etiological treatment in addition to cardiac medical treatment. Until now, there is no standard treatment for lupus myocarditis, but the use of mycophenolate mofetil seems to be a promising treatment.

Cardiac Manifestations of Systemic Lupus Erythematous: An Overview of the Incidence, Risk Factors, Diagnostic Criteria, Pathophysiology and Treatment Options

Systemic lupus erythematosus (SLE) is a complex connective tissue disease that can potentially affect every organ of the human body. In some cases, SLE may present with diverse cardiac manifestations including pericarditis, myocarditis, valvular disease, atherosclerosis, thrombosis, and arrhythmias. Heart disease in SLE is associated with increased morbidity and mortality. It is unclear whether traditional treatments for coronary artery disease significantly impact mortality in this population. Current therapeutic agents for SLE include glucocorticoids, hydroxychloroquine, mycophenolate mofetil, azathioprine, methotrexate, cyclophosphamide, and B cell-directed therapies. This article will provide a comprehensive review and update on this important disease state.

Increased long-term risk of heart failure and other adverse cardiac outcomes in dermatomyositis and polymyositis: Insights from a nationwide cohort

BACKGROUND

Mounting evidence suggests that dermatomyositis/polymyositis (DM/PM) are associated with increased risk of atherosclerotic events and venous thromboembolism. However, data on the association between DM/PM and other cardiac outcomes, especially heart failure (HF), are scarce.

OBJECTIVES

To examine the long-term risk and prognosis associated with adverse cardiac outcomes in patients with DM/PM.

METHODS

Using Danish administrative registries, we included all patients ≥18 years with newly diagnosed DM/PM (1996-2018). Risks of incident outcomes were compared with non-DM/PM controls from the background population (matched 1:4 by age, sex, and comorbidity). In a secondary analysis, we compared mortality following HF diagnosis between DM/PM patients with HF and non-DM/PM patients with HF (matched 1:4 by age and sex).

RESULTS

The study population included 936 DM/PM patients (median age 58.5 years, 59.0% women) and 3744 matched non-DM/PM controls. The median follow-up was 6.9 years. Absolute 10-year risks of incident outcomes for DM/PM patients vs matched controls were as follows: HF, 6.98% (CI, 5.16-9.16%) vs 4.58% (3.79-5.47%) (P = 0.002); atrial fibrillation, 10.17% (7.94-12.71%) vs 7.07% (6.09-8.15%) (P = 0.005); the composite of ICD implantation/ventricular arrhythmias/cardiac arrest, 1.99% (1.12-3.27%) vs 0.64% (0.40-0.98%) (P = 0.02); and all-cause mortality, 35.42% (31.64-39.21%) vs 16.57% (15.10-18.10%) (P < 0.0001). DM/PM with subsequent HF was associated with higher mortality compared with HF without DM/PM (adjusted hazard ratio 1.58 [CI, 1.01-2.47]).

CONCLUSION

Patients with DM/PM had a higher associated risk of HF and other adverse cardiac outcomes compared with matched controls. Among patients developing HF, a history of DM/PM was associated with higher mortality.

Systemic Lupus Erythematosus and Critical Illness

Systemic lupus erythematosus is a chronic autoimmune disorder that causes a wide range of mild to life-threatening conditions that require hospitalization and critical care. The morbidity and mortality of systemic lupus erythematosus are associated with the organ system damage caused by intermittent or chronic disease activity and with the complications of long-term and toxic immunosuppressant medication regimens. This article reviews the epidemiologic, clinical, diagnostic, and therapeutic information essential for critical care clinicians who provide care to patients with systemic lupus erythematosus.

Case report of an acute myocardial infarction complicated by coronary spasm in a patient with chronic systemic lupus erythematosus

Acute myocardial infarction (AMI) is a major cause of death in a patient with systemic lupus erythematosus (SLE). Due to their chronic inflammatory state, patient with SLE has an increased risk of developing coronary artery disease. We report a case of a middle-aged woman with an acute myocardial infarction (AMI) caused by a right coronary artery (RCA) stenosis complicated with severe coronary artery spasm. Our patient has a history of long-standing SLE. Clinical expression of coronary artery disease (CAD) in SLE is the result of different pathophysiologic mechanism. From this case, we raise the importance of the clinician to be aware of the diverse pathophysiologic pathways involving a coronary artery in a patient with SLE.

Systemic Lupus Erythematosus Complicated with Hypertrophic Cardiomyopathy: A Case Report and Literature Review

A 32-year-old female with systemic lupus erythematosus (SLE) for more than 7 years, and long-term treatment with cyclophosphamide, cyclosporine, methotrexate, and tacrolimus, later found to be combined with hypertrophic cardiomyopathy (HCM) for one year. The patient denied a family history of cardiomyopathy and sudden cardiac death (SCD). Echocardiography suggested that uneven thickening of the left ventricle (LV), mainly in the lower middle segment. Cardiac magnetic resonance (CMR) showed that the walls of the left ventricular (LV) were significantly thickened, as about 21 mm, mainly in the middle and lower segments. Genetic tests showed no known or suspected pathogenic variations were found and no significant enhancement in CMR, so secondary HCM was diagnosed clinically. After symptomatic treatment, the patient was discharged, and long-term follow-up was conducted. The diagnosis of HCM, which combined with SLE or second to usage of tacrolimus, was based on symptoms, echocardiography, and CMR; no endomyocardial biopsies were performed.

Cardiac manifestations of rheumatic diseases

Autoimmune rheumatic diseases are inflammatory disorders that can involve multiple organs, including the heart. The high risk of cardiovascular pathology in these patients is not only due to traditional cardiovascular risk factors, but also to chronic inflammation and autoimmunity. All cardiac structures may be affected during the course of systemic autoimmune diseases (valves, the conduction system, the myocardium, endocardium and pericardium, and coronary arteries), and the cardiac complications have a variety of clinical manifestations. As these are all associated with an unfavourable prognosis, it is essential to detect subclinical cardiac involvement in asymptomatic systemic autoimmune disease patients and begin adequate management and treatment early. In this review, we examine the multiple cardiovascular manifestations in patients with rheumatological disorders and available management strategies.

Long-Term Cardiovascular Outcomes in Systemic Lupus Erythematosus

BACKGROUND

Data on long-term cardiovascular outcomes in systemic lupus erythematosus (SLE) are sparse.

OBJECTIVES

This study sought to examine the long-term risk and prognosis associated with cardiovascular outcomes, including heart failure (HF), in patients with SLE.

METHODS

Using Danish administrative registries, risks of outcomes were compared between SLE patients (diagnosed 1996 to 2018, no history of cardiovascular disease) and age-, sex-, and comorbidity-matched control subjects from the background population (matched 1:4). Furthermore, mortality following HF diagnosis was compared between SLE patients developing HF and age- and sex-matched non-SLE control subjects with HF (matched 1:4).

RESULTS

A total of 3,411 SLE patients (median age: 44.6 years [25th to 75th percentile: 31.9 to 57.0 years]; 14.1% men) were matched with 13,644 control subjects. The median follow-up was 8.5 years (25th to 75th percentile: 4.0 to 14.4 years). Absolute 10-year risks of outcomes were: HF, 3.71% (95% confidence interval [CI]: 3.02% to 4.51%) for SLE patients, 1.94% (95% CI: 1.68% to 2.24%) for control subjects; atrial fibrillation, 4.35% (95% CI: 3.61% to 5.18%) for SLE patients, 2.82% (95% CI: 2.50% to 3.16%) for control subjects; ischemic stroke, 3.75% (95% CI: 3.06% to 4.54%) for SLE patients, 1.92% (95% CI: 1.66% to 2.20%) for control subjects; myocardial infarction, 2.17% (95% CI: 1.66% to 2.80%) for SLE patients, 1.49% (95% CI: 1.26% to 1.75%) for control subjects; venous thromboembolism, 6.03% (95% CI: 5.17% to 6.98%) for SLE patients, 1.68% (95% CI: 1.44% to 1.95%) for control subjects; and the composite of implantable cardioverter-defibrillator implantation/ventricular arrhythmias/cardiac arrest, 0.89% (95% CI: 0.58% to 1.31%) for SLE patients, 0.30% (95% CI: 0.20% to 0.43%) for control subjects. SLE with subsequent HF was associated with higher mortality compared with HF without SLE (adjusted hazard ratio: 1.50; 95% CI: 1.08 to 2.08).

CONCLUSIONS

SLE patients had a higher associated risk of HF and other cardiovascular outcomes compared with matched control subjects. Among patients developing HF, a history of SLE was associated with higher mortality.

Resolution of huge thrombi in bilateral ventricles caused by severe lupus cardiomyopathy

Ventricular thrombus is an uncommon, severe condition with high morbidity and mortality. Simultaneous left and right ventricular thrombi caused by lupus myocardiopathy have not been previously reported in the literature. This case presents a 42-year-old woman who has bilateral ventricular thrombi with reduced left ventricular ejection fraction (35.4%) and acute kidney injury. Pro-brain natriuretic peptide was >35000 pg/mL. Systemic lupus erythematosus was confirmed based on multiorgan injuries including malar rash, anemia, renal injury, positive antinuclear, anti-Smith antibodies, and decreased complements. Renal biopsy revealed lupus nephritis class III + V. Low molecular weight heparin, steroids, and mycophenolate mofetil were initiated, after which the patient experienced transient numbness in the right limbs and hemoptysis. She then recovered quickly and improved significantly with recovery of left ventricular systolic function (left ventricular ejection fraction 46%) and the eventual disappearance of thrombi. Simultaneous left and right ventricular thrombi are rare but life-threatening condition, prompting consideration of myocardiopathy caused by autoimmune diseases such as lupus. Timely treatment with immunosuppressants and anticoagulants may resolve the thrombi and improve cardiac function.

Myocardial rupture and systemic lupus erythematosus: a case report

Background

Systemic erythematous lupus (SLE) is an autoimmune disease associated with significant cardiovascular morbidity and mortality, even in young patients.

Case summary

A young female with recently diagnosed SLE under corticotherapy developed pulmonary oedema and respiratory failure. The diagnostic workup revealed mildly elevated cardiac troponin, significantly elevated NT-proB-type natriuretic peptide (NT-proBNP) and mild pericardial effusion without other echocardiographic abnormalities. Systemic erythematous lupus-associated myocarditis was presumed, and her clinical status improved after corticotherapy intensification. However, transthoracic echocardiogram repeated days later revealed a large pericardial effusion with findings suggestive of a contained myocardial rupture originating in the inferolateral basal left ventricular (LV) segment, which was confirmed by computed tomography scan. Cardiac catheterization exhibited normal coronary arteries. The patient was submitted to cardiac surgery and the LV pseudoaneurysm was successfully repaired.

Discussion

Myocardial rupture with LV pseudoaneurysm formation usually occurs in the setting of acute myocardial infarction, but also in other rare contexts. Cardiac rupture is associated with an extremely high mortality unless early diagnosis and urgent surgical intervention are provided.

Elevated C-reactive protein is significantly associated with left ventricular dysfunction in patients with aortic regurgitation and concomitant collagen disease

BACKGROUND

Collagen disease is an important cause of aortic regurgitation (AR). Although aortic valve surgery is recommended for patients with AR and depressed left ventricular (LV) function, there have been few reports about risk factors for LV dysfunction in patients with AR concomitant with collagen disease.

METHODS AND RESULTS

We conducted this study at Kumamoto University Hospital in Japan. A total of 41 patients who had moderate to severe AR and concomitant collagen disease between January 2014 and December 2019 were enrolled. With regard to baseline characteristics, there were no significant differences in the type of collagen disease or El Khoury class between patients with preserved LV function and those with reduced LV function. B-type natriuretic peptide (375.2 [257.9-3852.6]pg/ml vs. 64.0 [33.3-133.6]pg/ml, p < 0.01), C-reactive protein (CRP) levels (2.00 [1.24-9.14]mg/dl vs. 0.19 [0.06-0.52]mg/dl, p < 0.01) and neutrophil-to-lymphocyte ratio (7.94 [3.30-9.98] vs. 3.94 [1.83-5.58], p < 0.05) were significantly higher, and hemoglobin level (10.7 ± 1.6 g/dl vs. 12.2 ± 1.8 g/dl, p < 0.05) was significantly lower in patients with reduced LV function than in those with preserved LV function. There were no significant differences in any variables associated with severity and features of AR. Multivariable logistic regression analysis showed that high CRP levels (≥1.0 mg/dl) were independently and significantly associated with LV dysfunction in patients with AR and collagen disease, even after adjusting for the severity of AR (odds ratio: 95.7; 95% confidence interval: 4.6-1990.4, p < 0.01).

CONCLUSIONS

Uncontrolled inflammation, represented as high CRP levels, is an important marker for LV dysfunction in patients with AR and collagen disease.

Uncommon Coronary Abnormalities in a Patient with Discoid Lupus Erythematosus

A 43-year-old male presented with shortness of breath and palpitations. Physical examination was significant for skin lichenification, an erythematous maculopapular rash with annular plaques, a fissured tongue, and digital clubbing. Electrocardiogram captured a supraventricular tachycardia and right bundle branch block. Left heart catheterization found several proximal left coronary artery branch aneurysms, a right coronary-pulmonary artery fistula, venous-luminal vessels between the right heart chambers and cardiac veins, and thebesian venous lakes. Functional cardiac capacity was reduced, with left ventricular ejection fraction of 35 to 40%, on ventriculogram. A diagnosis of discoid lupus erythematosus was established after skin biopsies revealed systemic lupus erythematosus-like features but negative anti-nuclear, anti-Smith, anti-ds-deoxyribonucleic acid, anti-Ro, and anti-La antibodies. The case reported is unique, in that while our patient had pathologic electrophysiologic changes typically seen with autoimmune disease, the patient had many anatomical cardiac anomalies without atherosclerotic coronary disease. It is uncertain whether these findings are purely incidental or are related to an underlying genetic disorder.

Cardiac Conduction Defects in Systemic Lupus Erythematosus

Systemic autoimmune conditions may cause morbidity and mortality. Systemic lupus erythematosus (SLE) is a prominent example of such diseases. It can result in conduction abnormalities due to accelerated atherosclerosis, vasculitis, or autoantibodies-induced myocarditis. Cardiac conduction abnormalities may produce sinus tachycardia, sinus bradycardia, prolonged QT intervals, atrial fibrillation, or atrioventricular (AV) nodal blocks. Neonatal lupus is sometimes associated with anti-Ro/SSA and anti-La/SSB antibodies, but their role remains a matter of controversy in adults.

Pericarditis in Systemic Rheumatologic Diseases

PURPOSE OF REVIEW

We review the epidemiology, pathophysiology, and management of pericarditis most commonly complicating autoimmune and autoinflammatory conditions.

RECENT FINDINGS

Typically, pericarditis occurs in the context of a systemic flare of the underlying disease but infrequently, it is the presenting manifestation requiring a high index of suspicion to unravel the indolent cause. Pericardial involvement in rheumatic diseases encompasses a clinical spectrum to include acute, recurrent and incessant pericarditis, constrictive pericarditis, asymptomatic pericardial effusion, and pericardial tamponade. Direct evidence on the pathophysiology of pericarditis in the context of rheumatic diseases is scant. It is theorized that immune perturbations within pericardial tissue result from the underlying central immunopathology of the respective autoimmune or autoinflammatory disease. Pericarditis management depends on acuity, the underlying cause and epidemiological features such as patient's immune status and geographic prevalence of infections such as tuberculosis. Immunosuppressive medications including biologics such as interleukin 1 blockers emerge as possible steroid sparing agents for pericarditis treatment.

Systemic lupus erythematosus presenting with status epilepticus and acute cardiomyopathy with acute heart failure: case report

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.

Pediatric systemic lupus erythematosus patients in South Africa have high prevalence and severity of cardiac and vascular manifestations

BACKGROUND

Pediatric onset of systemic lupus erythematosus (SLE) is associated with major organ involvement, and African patients tend to develop more aggressive disease than patients of European descent. Although cardiovascular involvement is common in pediatric SLE, there are few published reports on the subject. This study describes the frequency and characteristics of cardiac and vascular manifestations of pediatric SLE in a multi-ethnic South African cohort.

METHODS

Demographic, clinical, and echocardiographic data were collected from pediatric SLE patients at two centers in Cape Town, South Africa. At the time of investigation, this cohort consisted of 93 participants diagnosed with SLE according to international classification criteria prior to the age of 19. Individuals with cardiac and/or vascular involvement were identified by retrospective chart review. Cardiac manifestations were defined as presence of pericardial effusion, myocarditis, cardiomyopathy, cardiac failure, Libman-Sacks endocarditis, myocardial infarction, and arrhythmia. Vascular manifestations included deep vein thrombosis, pulmonary embolism, sinus thrombosis, stroke, critical limb ischemia, cerebral vasculitis and systemic vasculitis. Statistical analysis was performed using R (v3.4.1).

RESULTS

Cardiac and vascular involvement was present in 47% of the cohort. Previous studies have reported prevalence of 5%-50%. Demographic features of those with cardiac/vascular involvement did not differ from the overall cohort. Echocardiographic data were available for 23 participants. The most common cardiac manifestations were pericardial effusion (n = 24) and cardiac failure (n = 8), while the most common vascular manifestations were cerebral vasculitis (n = 9), stroke (n = 7), and pulmonary embolism (n = 7). Cardiovascular manifestations were frequently severe; one third of pericardial effusion cases required intervention, including three cases of cardiac tamponade. Cardiac and vascular involvement conferred an increased risk of mortality (31.1% versus 10.4%).

CONCLUSIONS

Cardiac and vascular involvement were highly prevalent in this South African cohort. The mortality rate was high, and severe manifestations were frequent. Prospective research is needed to improve knowledge of pediatric SLE in Africa and to improve outcomes for this high-risk population.

Complete heart block in lupus

Conduction abnormalities are uncommon in adult patients with lupus. We present a young woman with recurrent syncope caused by third-degree atrio-ventricular block as the initial manifestation of lupus and review 31 additional cases of systemic lupus erythematosus patients that have been described previously with complete heart block. Heart blocks occurred almost exclusively in females. The median age was 37 years. In 24 cases heart blocks were diagnosed in patients with established lupus. In only five patients, including the patient presented here, heart blocks were diagnosed before the lupus diagnosis. Syncope was the most common presenting symptom of heart block. Electrocardiographic findings prior to heart block episodes were reported in 17 cases: eight had normal findings, but nine had already variant forms of atrioventricular or intraventricular conduction defects. Anti-nuclear antibody tests were reported in 25 cases and were all positive. Anti-DNA antibodies were also common and were positive in 16 of 19 cases (84%). Anti-La and anti-Ro antibodies were less common (13% and 35%, respectively). Three patients died, all prior to 1975. Heart block resolved in 10 cases. Follow-up was reported in four of these cases and heart block recurred in three of them. A permanent pacemaker was the eventual treatment in 22 cases. The etiology of lupus-associated complete heart block is not clear. It is probably variable, possibly related to effects of autoantibodies reacting with the conduction system, myocardial disease and adverse effects of antimalarials. Insertion of a permanent pacemaker seems to be the preferable method of treatment.

Myocarditis in Humans and in Experimental Animal Models

Myocarditis is defined as an inflammation of the cardiac muscle. In humans, various infectious and non-infectious triggers induce myocarditis with a broad spectrum of histological presentations and clinical symptoms of the disease. Myocarditis often resolves spontaneously, but some patients develop heart failure and require organ transplantation. The need to understand cellular and molecular mechanisms of inflammatory heart diseases led to the development of mouse models for experimental myocarditis. It has been shown that pathogenic agents inducing myocarditis in humans can often trigger the disease in mice. Due to multiple etiologies of inflammatory heart diseases in humans, a number of different experimental approaches have been developed to induce myocarditis in mice. Accordingly, experimental myocarditis in mice can be induced by infection with cardiotropic agents, such as coxsackievirus B3 and protozoan parasite Trypanosoma cruzi or by activating autoimmune responses against heart-specific antigens. In certain models, myocarditis is followed by the phenotype of dilated cardiomyopathy and the end stage of heart failure. This review describes the most commonly used mouse models of experimental myocarditis with a focus on the role of the innate and adaptive immune systems in induction and progression of the disease. The review discusses also advantages and limitations of individual mouse models in the context of the clinical manifestation and the course of the disease in humans. Finally, animal-free alternatives in myocarditis research are outlined.

Pericarditis in Lupus

Pericarditis is a common cardiac manifestation in systemic lupus erythematosus (SLE). Serositis is recognized in the ACR, SLICC, and EULAR/ACR classification criteria. We reviewed the prior research regarding the epidemiology, risk factors, presentation, and treatment of pericarditis in SLE.

Recurrent Pericarditis in Children and Adolescents

Recurrent pericarditis (RP) is a clinical syndrome characterized by recurrent attacks of acute pericardial inflammation. Prognosis quoad vitam is good, although morbidity might be significant, especially in children and adolescents. Multiple potential etiologies result in RP, in the vast majority of cases through autoimmune or autoinflammatory mechanisms. Idiopathic RP is one of the most frequent diagnoses, that requires the exclusion of all known etiologies. Therapeutic advances in the last decade have been significant with the recognition of the effectiveness of anti IL1 therapy, but a correct diagnostic and therapeutic algorithm is of key importance. Unfortunately, most of evidence comes from studies in adult patients. Here we review the etiopathogenesis, diagnosis and management of RP in pediatric patients.

Cardiac tamponade as the initial symptom due to systemic lupus erythematosus in a young man: A case report

RATIONALE

Systemic lupus erythematosus (SLE) is a connective tissue disease that has many clinical manifestations. However, cardiac tamponade has been rarely reported especially as an initial presenting feature of systemic lupus erythematosus. Herein, we describe a case of cardiac tamponade as the first presentation of systemic lupus erythematosus in a male and presented the course of diagnosis and treatment of this patient.

PATIENT CONCERNS

A 32-year-old male patient developed a rapid progression of pericardial effusion and he was almost healthy in the past. Vital signs were significantly marked by high fever, tachycardia, and accelerated breathing rate of 37 times per minute. The ANA titer was 1:320 and anti-dsDNA was positive during his hospitalization. The complement levels were decreased but the ESR and the CRP level were increased obviously. Soon after, he appeared anemic and thrombocytopenic.

DIAGNOSES

The diagnosis of SLE was made based on the clinical and biochemical findings according to 2012 SLICC SLE Criteria.

INTERVENTIONS

The interventions included use CT-guided pericardial puncture to relieve symptoms in time; utilize high-dose glucocorticoids and immunosuppressants to therapy SLE; closely monitor the vital signs, blood routine, blood biochemical indicators, and volume of pericardial effusion.

OUTCOMES

After 2 months, the symptoms were disappeared almost completely and TTE showed his pericardial effusion had decreased significantly.

LESSONS

We should also keep SLE in mind when assessing male patients with pericardial effusions. Early examinations of sero-immunological markers and closely monitoring the performances are important for the diagnosis of the disease. Early pericardial puncture can quickly relieve symptoms and improve prognosis.

Cardiac manifestations of Han Chinese patients with systemic lupus erythematosus: a retrospective study

OBJECTIVE

To investigate cardiac manifestations and the risk factors in Han Chinese patients with systemic lupus erythematosus (SLE).

METHODS

Seven hundred fifty SLE patients who were hospitalized at our department were recruited in the present study. The patients were divided into two groups-those with or without cardiac manifestations. Cardiac manifestations in those SLE patients, such as pericarditis, myocarditis, heart valve disease, arrhythmia, were analyzed. The risk and protective factors of cardiac diseases in patients with SLE, as well as the predictors of mortality, were assessed, respectively.

RESULTS

In all 750 SLE patients, there were 339 (45.20%) patients suffered from one or more cardiac manifestations, involving pericarditis in 9.5%, myocarditis in 5.7%, heart valve disease in 15.6%, arrhythmia in 16.67%, and cardiovascular diseases (CVD) in 14%. 15.7% of SLE patients were accompanied with pulmonary arterial hypertension (PAH), of which 13.7% were mild, 1.2% were moderate, and 0.8% were severe. No significant differences were found between the two groups in age, disease duration, gender, antibody, and Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). The incidence of pericarditis, heart valve disease, arrhythmia, and PAH was positively correlated with age. The incidence of arrhythmia, CVD, and PAH was correlated with SLEDAI. PAH and myocarditis were the risk factors of mortality in SLE patients with disease duration ≤ 10 years (P = 0.034 and 0.001, respectively).

CONCLUSION

Cardiac involvement is common in Han Chinese SLE patients and associated with age and disease activity. PAH and myocarditis are the risk factors of mortality in SLE.

Myocarditis in systemic lupus erythematosus diagnosed by 18F-fluorodeoxyglucose positron emission tomography

OBJECTIVES

Cardiovascular diseaseand heart failure (CHF) are leading causes of death in systemic lupus erythematosus (SLE). The underlying mechanisms for increased CHF in SLE are unclear but myocardial inflammation and lupus myocarditis (LM) may play a role. We propose that 18F-fluorodeoxyglucose-positron emission tomography (18F-FDG-PET)/CT can help diagnose LM.

METHODS

This report describes eight patients with presumed LM; five patients were evaluated due to active cardiorespiratory symptoms and three patients were participating in a pilot study to determine the prevalence of subclinical myocarditis in SLE. Clinical characteristics, laboratory and cardiac testing including electrocardiography (ECG), transthoracic echocardiogram (TTE), coronary artery evaluation as well as 18F-FDG-PET/CT imaging are discussed.

RESULTS

Four patients were African American and the others were Hispanic. Half presented with chest pain; 37% had dyspnoea and 25% were asymptomatic. The median SLE Disease Activity Index (SLEDAI-2K) was 5 (2-18) and SLICC Damage Index (SDI) 0.5 (0-5). The median troponin level was 0.08 ng/mL (0-0.9). The most common ECG findings were non-specific ST-T wave abnormalities (n=5). Fifty per cent of the patients had a decreased ejection fraction on TTE and all patients had diffuse myocardial FDG uptake on 18F-FDG-PET/CT consistent with myocardial inflammation.

CONCLUSION

This case series is the first to describe the use of 18F-FDG-PET/CT in the diagnosis of LM and discuss the clinical characteristics and cardiac findings of eight patients with LM supporting the role for cardiac 18F-FDG-PET/CT in its diagnosis.