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Batani V, Dagna L, De Luca G. Therapeutic strategies for primary heart involvement in systemic sclerosis. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2024; 5:72-82. [PMID: 39015843 PMCID: PMC11248560 DOI: 10.1515/rir-2024-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/11/2024] [Indexed: 07/18/2024]
Abstract
Primary heart involvement (pHI) is frequent in systemic sclerosis (SSc), even though often underdiagnosed. SSc-pHI has been recently defined as cardiac abnormalities that are predominantly attributable to SSc rather than other causes and/or complications. SSc-pHI represents a major determinant of mortality in SSc, accounting alone for about 12% of disease-related deaths; its early recognition and promptly therapeutic interventions are therefore crucial. Both perfusion defects and myocardial inflammation contribute to the occurrence of myocardial fibrosis that precipitates myocardial remodeling, potentially leading to heart failure and arrhythmic complications. To date, clear evidence and guidelines for effectively managing SSc pHI are not established yet, resulting in a lack of a defined therapeutic algorithm. In this review we summarize the most recent scientific literature on the prevailing therapeutic strategies and interventions to manage SSc-pHI, with particular focus on therapeutic strategies to counteract the 3 major pathogenic events of the disease, i.e. microvascular damage, myocardial inflammation and myocardial fibrosis.
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Affiliation(s)
- Veronica Batani
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Dagna
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giacomo De Luca
- Vita-Salute San Raffaele University, Milan, Italy
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
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2
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Azzam M, Awad A, Abugharbyeh A, Kahaleh B. Myocarditis in connective tissue diseases: an often-overlooked clinical manifestation. Rheumatol Int 2023; 43:1983-1992. [PMID: 37587233 DOI: 10.1007/s00296-023-05428-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 08/18/2023]
Abstract
To discuss what is currently known about myocarditis in the context of major connective tissue diseases, including Systemic lupus erythematosus, Rheumatoid Arthritis, Sjogren, Dermato-myositis and Polymyositis, Systemic Sclerosis, and Mixed connective tissue disease. Variability exists between studies regarding the incidence of myocarditis in connective tissue diseases, which is hypothesized to be the result of its subclinical course in most cases. Extensive gaps of knowledge exist in the field of pathophysiology. Although endomyocardial biopsy remains to be the gold standard for diagnosis, the advancement in non-invasive modalities such as cardiac MRI, echocardiography, and nuclear medicine has allowed for earlier and more frequent detection of myocarditis. A lack of treatment guidelines was found across the different connective tissue diseases. Most of the literature available revolved around myocarditis in the context of Systemic lupus erythematosus. Numerous recent studies were published that contributed to advancements in diagnosis and treatment however, there remains a lack of diagnostic and treatment guidelines.
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Affiliation(s)
- Muayad Azzam
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan.
| | - Amro Awad
- Faculty of Medicine, The University of Jordan, Amman, 11942, Jordan
| | - Aya Abugharbyeh
- Division of Rheumatology and Immunology, University of Toledo Medical Center, Toledo, USA
| | - Bashar Kahaleh
- Division of Rheumatology and Immunology, University of Toledo Medical Center, Toledo, USA
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Santos A, Kure C, Sanchez C, Gross P. The Diagnostic Dilemma of "The Great Imitator": Heart and Cerebral Involvement of Lupus Manifesting as Bilateral Upper and Lower Extremity Weakness. Case Rep Rheumatol 2023; 2023:6676357. [PMID: 37854887 PMCID: PMC10581839 DOI: 10.1155/2023/6676357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/21/2023] [Accepted: 09/27/2023] [Indexed: 10/20/2023] Open
Abstract
Background Systemic lupus erythematous (SLE) is an autoimmune condition which can cause complex, multiorgan dysfunction. This autoimmune disease is caused by the production of antinuclear antibodies which allows this disease to target virtually any organ in the human body. When a patient experiences an unpredictable worsening of disease activity, it is generally considered a lupus flare. Organ dysfunction due to a lupus flare tends to manifest as separate events in the literature and rarely do we witness multiple compounding organ failures during a lupus flare. If we do witness organ dysfunction and failure, rarely do we see cardiac and cerebral involvement. Typically, patients take immunosuppressants for a long term to avoid the patient's disease process from worsening and to provide prophylaxis from a flare to occur. Despite the availability in preventive strategies, some patients will have increased disease activity multiple times throughout their lifetime and will need increases in their medication doses or changes to their regimen. Some flares can be managed in the clinic, but more severe ones may be life-threatening that they require intravenous medications and hospitalization to achieve remission. In the following case, we see a patient with a past medical history of SLE on multiple immunosuppressants who arrived at the hospital with acute, bilateral weakness of the upper and lower extremities. It was later determined via various imaging and laboratory testing that she was having an SLE flare that was directly causing myocarditis which progressed to global ischemia of the brain via myocardial hypoperfusion. She experienced substantial recovery from her flare with treatment with high-dose, intravenous corticosteroids. Case Report. A 27-year-old female with a 2-year history of lupus and a 1-week history of paroxysmal atrial fibrillation presented with three days of bilateral focal neurological deficits in the arms and legs. She was found to have ischemic cardiac and neurologic manifestations during her hospital stay. Conclusion Our patient presented with reversible focal neurological deficits, elevated high-sensitive troponin levels, and high lupus serum antibodies who showed significant improvement after the introduction of high-dose steroids. This case recommends keeping a large differential and to not discount patients' past comorbidities for causing atypical symptomatology.
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Affiliation(s)
| | - Catrina Kure
- Northeast Georgia Medical Center, Gainesville, USA
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Nor MA, Ogedegbe OJ, Barbarawi A, Ali AI, Sheikh IM, Yussuf FM, Adam SM, Hassan OA, Tabowei G, Jimoh A, Mejulu EO, Cheema AY. Systemic Lupus Erythematosus and Cardiovascular Diseases: A Systematic Review. Cureus 2023; 15:e39284. [PMID: 37346216 PMCID: PMC10280490 DOI: 10.7759/cureus.39284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/23/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune condition characterized by multi-organ involvement. The clinical presentation often varies from mild to moderate to severe. The cardiovascular system may also be affected, often portending a poor prognosis for patients. Although the relationship between SLE and cardiovascular disorders has been extensively explored through case reports and literature reviews, few systematic reviews explicitly focusing on this association have been conducted. In light of this, this systematic review aims to analyze the extent of the association between SLE and cardiovascular diseases (CVDs), by exploring the risk of developing CVDs, including myocardial infarction (MI), atherosclerosis, myocarditis, pericarditis and arrhythmias, in SLE patients vs. non-SLE patients. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform the systematic review. A detailed search was done covering the period from March 2003 to March 2023 using three databases: PubMed, Google Scholar, and Cochrane. The PubMed search identified 597 articles, while Google Scholar and Cochrane searches yielded 559 and three articles, respectively. Of the 1159 articles retrieved, we chose eight for final consideration, after excluding papers that did not discuss the role of SLE in CVDs, papers published earlier than 2003, and papers with incomplete data. The eight studies chosen included two narrative reviews, two systematic reviews, and four observational studies. In this systematic review, SLE was proven to have a strong relationship with diverse CVDs, including rare ones scarcely discussed in the literature, such as vasculitis and aortic dissection. All eight of the final papers indicated a connection between SLE and CVDs, based on the systematic analysis of these articles, which revealed that most recent research supports a higher risk of peripheral arterial occlusive disease (PAOD), MI, pericarditis, myocarditis, and other cardiovascular disorders in individuals with SLE. These associations may have certain gray areas, as patient characteristics and comorbidities often affect the extent of illness and long-term prognosis. Larger-scale studies are required to probe this relationship further and research the etiopathogenesis involved in order to improve patient outcomes. The effects of SLE on the heart are, however, unequivocal.
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Affiliation(s)
- Mohammed A Nor
- Internal Medicine, Stamford Hospital/Columbia University Vagelos College of Physicians and Surgeons for Internal Medicine, Stamford City, USA
| | | | - Ahmed Barbarawi
- Internal Medicine, University of Minnesota, Minneapolis, USA
| | | | | | | | | | - Omar A Hassan
- General Practice, Ondokuz Mayis University, Samsun, TUR
| | - Godfrey Tabowei
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Abdulmalik Jimoh
- Internal Medicine, Mount Horeb Clinic and Dialysis Center, Warri, NGA
| | | | - Asfand Yar Cheema
- Medicine, Services Hospital, Lahore, PAK
- Internal Medicine, Lahore Medical and Dental College, Lahore, PAK
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Ikić Matijašević M, Grubić Rotkvić P, Planinić Z, Ikić L, Zadro Kordić I, Galić E. Perimyocarditis as First Manifestation of Systemic Lupus Erythematosus Successfully Treated with Heart Failure and Immunosuppressive Therapy. J Cardiovasc Dev Dis 2023; 10:jcdd10040134. [PMID: 37103013 PMCID: PMC10143379 DOI: 10.3390/jcdd10040134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 04/28/2023] Open
Abstract
Systemic lupus erythematosus (SLE) myocarditis is presumed to be rare, but associated with adverse outcomes. If SLE diagnosis has not previously been established, its clinical presentation is often unspecific and difficult to recognize. Furthermore, there is a lack of data in the scientific literature regarding myocarditis and its treatment in systemic immune-mediated diseases, leading to its late recognition and undertreatment. We present the case of a young woman whose first lupus manifestations included acute perimyocarditis, among other symptoms and signs that provided clues to the diagnosis of SLE. Transthoracic and speckle tracking echocardiography were helpful in detecting early abnormalities in the myocardial wall thickness and contractility while waiting for cardiac magnetic resonance. Since the patient presented with acute decompensated heart failure (HF), HF treatment was promptly started in parallel with immunosuppressive therapy, with a good response. In the treatment of myocarditis with heart failure, we were guided by the clinical signs, echocardiographic findings, biomarkers of myocardial stress, necrosis, and systemic inflammation, as well as markers of SLE disease activity.
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Affiliation(s)
- Marina Ikić Matijašević
- Internal Medicine Clinic, University Hospital Sveti Duh, 10 000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10 000 Zagreb, Croatia
| | | | - Zrinka Planinić
- Internal Medicine Clinic, University Hospital Sveti Duh, 10 000 Zagreb, Croatia
| | - Lucija Ikić
- Department of Anatomy and Physiology, University of Applied Health Sciences, 10 000 Zagreb, Croatia
| | - Ines Zadro Kordić
- Internal Medicine Clinic, University Hospital Sveti Duh, 10 000 Zagreb, Croatia
| | - Edvard Galić
- Internal Medicine Clinic, University Hospital Sveti Duh, 10 000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10 000 Zagreb, Croatia
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du Toit R, Karamchand S, Doubell AF, Reuter H, Herbst PG. Lupus myocarditis: review of current diagnostic modalities and their application in clinical practice. Rheumatology (Oxford) 2023; 62:523-534. [PMID: 35861382 DOI: 10.1093/rheumatology/keac409] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 02/04/2023] Open
Abstract
Lupus myocarditis (LM) is a potentially fatal manifestation of SLE, occurring in 5-10% of patients. Clinical manifestations may vary from an unexplained tachycardia to fulminant congestive cardiac failure (CCF). With no single clinical or imaging modality being diagnostic, a rational and practical approach to the patient presenting with possible LM is essential. Markers of myocyte injury (including troponin I and creatine kinase) may be unelevated and do not exclude a diagnosis of LM. Findings on ECG are non-specific but remain essential to exclude other causes of CCF such as an acute coronary syndrome or conduction disorders. Echocardiographic modalities including wall motion abnormalities and speckle tracking echocardiography may demonstrate regional and/or global left ventricular dysfunction and is more sensitive than conventional echocardiography, especially early in the course of LM. Cardiac magnetic resonance imaging (CMRI) is regarded as the non-invasive diagnostic modality of choice in myocarditis. While more sensitive and specific than echocardiography, CMRI has certain limitations in the context of SLE, including technical challenges in acutely unwell and uncooperative patients, contraindications to gadolinium use in the context of renal impairment (including lupus nephritis) and limited literature regarding the application of recommended diagnostic CMRI criteria in SLE. Both echocardiography as well as CMRI may detect subclinical myocardial dysfunction and/or injury of which the clinical significance remains uncertain. Considering these challenges, a combined decision-making approach by rheumatologists and cardiologists interpreting diagnostic test results within the clinical context of the patient is essential to ensure an accurate, early diagnosis of LM.
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Affiliation(s)
| | | | | | - Helmuth Reuter
- Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Schattner A. Unusual Presentations of Systemic Lupus Erythematosus: A Narrative Review. Am J Med 2022; 135:1178-1187. [PMID: 35671786 DOI: 10.1016/j.amjmed.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/01/2022] [Accepted: 05/16/2022] [Indexed: 11/01/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease characterized by an almost 10:1 female predominance, the presence of deleterious nuclear autoantibodies, a tendency for flare, and striking protean manifestations. Early diagnosis is associated with less damage accrual, lower costs, and improved quality of life due to timely treatment. However, early disease may not uncommonly show nonspecific presentation, a single classification criterion, or an unusual organ involvement contributing to frequent, often substantial diagnostic delays. We reviewed the literature (1982-2022) to accumulate and classify all reports of rare, atypical, and unusual presentations. These can involve almost every organ and system, and thus, present to physicians in every discipline and setting. Increasing physicians' awareness of the potential of occult SLE to appear in varied, diverse, and unexpected presentations, may encourage the inclusion of SLE in the differential. Informed history and examination focusing on systemic and joint symptoms and mucocutaneous involvement, and basic tests (focusing on leukopenia, thrombocytopenia, and proteinuria; followed by antinuclear antibodies and complement levels) will correctly diagnose most patients on presentation or within the following months and enable timely treatment.
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Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel.
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8
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Kasitanon N, Hamijoyo L, Li MT, Oku K, Navarra S, Tanaka Y, Mok CC. Management of non-renal manifestations of systemic lupus erythematosus: A systematic literature review for the APLAR consensus statements. Int J Rheum Dis 2022; 25:1220-1229. [PMID: 35916201 DOI: 10.1111/1756-185x.14413] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/31/2022] [Accepted: 07/03/2022] [Indexed: 11/30/2022]
Abstract
The prevalence of systemic lupus erythematosus (SLE) is higher in Asians than Caucasians, with higher frequency of renal and other major organ manifestations that carry a poorer prognosis. The outcome of SLE is still unsatisfactory in many parts of the Asia Pacific region due to limited access to healthcare systems, poor treatment adherence and adverse reactions to therapies. The Asia Pacific League of Associations for Rheumatology (APLAR) SLE special interest group has recently published a set of consensus recommendation statements for the management of SLE in the Asia Pacific region. The current article is a supplement of systematic literature search (SLR) to the prevalence and treatment of non-renal manifestations of SLE in Asian patients.
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Affiliation(s)
- Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Laniyati Hamijoyo
- Rheumatology Division, Department of Internal Medicine, Padjadjaran University, Bandung, Indonesia
| | - Meng Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas Hospital, Manila, Philippines
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
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9
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Shi YJ, Wang LF, Ma J, Chen Y, Wang WJ, Xie CY. Veno-Arterial Extracorporeal Membrane Oxygenation in the Treatment of Hemodynamically Unstable Lupus Myocarditis: A Retrospective Case Series Study. J Inflamm Res 2022; 15:3761-3768. [PMID: 35815067 PMCID: PMC9270012 DOI: 10.2147/jir.s365399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/17/2022] [Indexed: 11/23/2022] Open
Abstract
Objective The clinical manifestations and treatment of three patients with hemodynamically unstable lupus myocarditis (LM) were analyzed. Methods The clinical data of three patients with LM with hemodynamic instability, who were admitted to the emergency ICU of the south hospital of the Renji Hospital, School of Medicine, Shanghai Jiao Tong University of Medicine from January 2018 to December 2021, were collected and analyzed, and relevant literatures were reviewed. Results Two of the three patients had the first onset of systemic lupus erythematosus. The other patient had mixed connective tissue disease in the past, and lupus was the main manifestation of this disease. At the onset of the disease, all patients had chest tightness and shortness of breath; two patients had a fever, and the markers of myocardial injury increased. Cardiac color Doppler ultrasound indicated that left ventricular ejection fraction decreased significantly. Cardiac insufficiency with cardiogenic shock rapidly appeared as the main manifestation. Two patients immediately started veno-arterial extracorporeal membrane oxygenation (VA-ECMO), and ECMO was also started in one patient after a pacemaker placement was ineffective. For all three patients, high-dose hormones were given to control the primary disease, and then the ECMO machines were removed successfully. Conclusion VA-ECMO treatment should be implemented in patients with hemodynamically unstable LM as soon as possible to maintain the patient’s hemodynamics and help them overcome the crisis of cardiac dysfunction, allowing more time for primary disease treatment.
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Affiliation(s)
- Yu-Jun Shi
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Li-Feng Wang
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Jun Ma
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Yi Chen
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Wei-Jun Wang
- Department of Cardiovascular Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Cui-Ying Xie
- Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
- Correspondence: Cui-Ying Xie, Department of Emergency, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People’s Republic of China, Tel +86 13817204797, Email
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10
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Sairam S, Sureen A, Gutierrez J, Dang TQ, Mishra K. Cardiovascular Outcomes in Systemic Lupus Erythematosus. Curr Cardiol Rep 2022; 24:75-83. [PMID: 35028818 DOI: 10.1007/s11886-021-01626-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE OF THE REVIEW To review cardiovascular outcomes (CVE) in systemic lupus erythematosus (SLE) that evolves over time. RECENT FINDINGS Inception cohorts now report long-term data, and large population registries add to our knowledge. Mortality and cardiovascular morbidity remain high with a risk ratio of 2-3. SLE disease activity-related inflammation accounts for higher CVE incidence ratio in the first year following diagnosis with accelerated atherosclerosis contributing to CVE in about a quarter to a third of the patients later in the disease course. Immunomodulation and disease control are associated with improved cardiovascular outcomes. Validation of modified risk stratification tools and studies evaluating primary prevention with aspirin and hydroxychloroquine are reported. Increased awareness of high mortality associated with cardiac inflammation, improved outcomes with early disease control, aggressive management of risk factors, hypertension, obesity, and high cholesterol with modifying risk stratification will result in more favorable outcomes in SLE patients.
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Affiliation(s)
- Shrilekha Sairam
- Division of Rheumatology, Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech Health Sciences Center El Paso, El Paso, TX, USA.
| | - Amit Sureen
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
| | - Jesus Gutierrez
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
| | - The Q Dang
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
| | - Kunal Mishra
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA
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11
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Cheng CY, Baritussio A, Giordani AS, Iliceto S, Marcolongo R, Caforio ALP. Myocarditis in systemic immune-mediated diseases: Prevalence, characteristics and prognosis. A systematic review. Autoimmun Rev 2022; 21:103037. [PMID: 34995763 DOI: 10.1016/j.autrev.2022.103037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 01/02/2022] [Indexed: 12/17/2022]
Abstract
Many systemic immune-mediated diseases (SIDs) may involve the heart and present as myocarditis with different histopathological pictures, i.e. lymphocytic, eosinophilic, granulomatous, and clinical features, ranging from a completely asymptomatic patient to life-threatening cardiogenic shock or arrhythmias. Myocarditis can be part of some SIDs, such as sarcoidosis, systemic lupus erythematosus, systemic sclerosis, antiphospholipid syndrome, dermato-polymyositis, eosinophilic granulomatosis with polyangiitis and other vasculitis syndromes, but also of some organ-based immune-mediated diseases with systemic expression, such as chronic inflammatory bowel diseases. The aim of this review is to describe the prevalence, main clinical characteristics and prognosis of myocarditis associated with SIDs.
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Affiliation(s)
- Chun-Yan Cheng
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Anna Baritussio
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Andrea Silvio Giordani
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Renzo Marcolongo
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Alida L P Caforio
- Cardiology, Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy.
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12
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Zagelbaum Ward NK, Linares-Koloffon C, Posligua A, Gandrabur L, Kim WY, Sperber K, Wasserman A, Ash J. Cardiac Manifestations of Systemic Lupus Erythematous: An Overview of the Incidence, Risk Factors, Diagnostic Criteria, Pathophysiology and Treatment Options. Cardiol Rev 2022; 30:38-43. [PMID: 32991394 DOI: 10.1097/crd.0000000000000358] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Nicole K Zagelbaum Ward
- From the Department of Rheumatology, Keck School of Medicine/University of Southern California, Los Angeles, CA
| | - Carlos Linares-Koloffon
- Yale Center for Asthma and Airway Disease, Yale University School of Medicine, New Haven, CT
| | - Alba Posligua
- Department of Medicine and Division of Rheumatology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Liliya Gandrabur
- Department of Medicine and Division of Rheumatology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Woo Young Kim
- Department of Medicine and Division of Rheumatology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Kirk Sperber
- Department of Medicine and Division of Rheumatology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Amy Wasserman
- Department of Medicine and Division of Rheumatology, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Julia Ash
- Department of Medicine and Division of Rheumatology, Westchester Medical Center and New York Medical College, Valhalla, NY
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13
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Raval JJ, Ruiz CR, Heywood J, Weiner JJ. SLE strikes the heart! A rare presentation of SLE myocarditis presenting as cardiogenic shock. BMC Cardiovasc Disord 2021; 21:294. [PMID: 34120592 PMCID: PMC8201668 DOI: 10.1186/s12872-021-02102-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/06/2021] [Indexed: 11/15/2022] Open
Abstract
Background Although systemic lupus erythematosus (SLE) can affect the cardiovascular system in many ways with diverse presentations, a severe cardiogenic shock secondary to SLE myocarditis is infrequently described in the medical literature. Variable presenting features of SLE myocarditis can also make the diagnosis challenging. This case report will allow learners to consider SLE myocarditis in the differential and appreciate the diagnostic uncertainty.
Case presentation A 20-year-old Filipino male presented with acute dyspnea, pleuritic chest pain, fevers, and diffuse rash after being diagnosed with SLE six months ago and treated with hydroxychloroquine. Labs were notable for leukopenia, non-nephrotic range proteinuria, elevated cardiac biomarkers, inflammatory markers, low complements, and serologies suggestive of active SLE. Broad-spectrum IV antibiotics and corticosteroids were initiated for sepsis and SLE activity. Blood cultures were positive for MSSA with likely skin source. An electrocardiogram showed diffuse ST-segment elevations without ischemic changes. CT chest demonstrated bilateral pleural and pericardial effusions with dense consolidations. Transthoracic and transesophageal echocardiogram demonstrated reduced left ventricular ejection fraction (LVEF) 45% with no valvular pathology suggestive of endocarditis. Although MSSA bacteremia resolved, the patient rapidly developed cardiopulmonary decline with a repeat echocardiogram demonstrating LVEF < 10%. A Cardiac MRI was a nondiagnostic study to elucidate an etiology of decompensation given inability to perform late gadolinium enhancement. Later, cardiac catheterization revealed normal cardiac output with non-obstructive coronary artery disease. As there was no clear etiology explaining his dramatic heart failure, endomyocardial biopsy was obtained demonstrating diffuse myofiber degeneration and inflammation. These pathological findings, in addition to skin biopsy demonstrating lichenoid dermatitis with a granular “full house” pattern was most consistent with SLE myocarditis. Furthermore, aggressive SLE-directed therapy demonstrated near full recovery of his heart failure. Conclusion Although myocarditis during SLE flare is a well-described cardiac manifestation, progression to cardiogenic shock is infrequent and fatal. As such, SLE myocarditis should be promptly considered. Given the heterogenous presentation of SLE, combination of serologic evaluation, advanced imaging, and myocardial biopsies can be helpful when diagnostic uncertainty exists. Our case highlights diagnostic methods and clinical course of a de novo presentation of cardiogenic shock from SLE myocarditis, then rapid improvement.
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Affiliation(s)
- Jaydeep J Raval
- Division of Rheumatology, Department of Internal Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA, 92134, USA.
| | - Christina Rodriguez Ruiz
- Department of Cardiology, Scripps Clinic/Green Hospital, San Diego, CA, USA.,, 9898 Genessee Ave, La Jolla, CA, 92037, USA
| | - James Heywood
- Department of Cardiology, Scripps Clinic/Green Hospital, San Diego, CA, USA.,, 9898 Genessee Ave, La Jolla, CA, 92037, USA
| | - Jason J Weiner
- Division of Rheumatology, Department of Internal Medicine, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA, 92134, USA
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Meridor K, Shoenfeld Y, Tayer-Shifman O, Levy Y. Lupus acute cardiomyopathy is highly responsive to intravenous immunoglobulin treatment: Case series and literature review. Medicine (Baltimore) 2021; 100:e25591. [PMID: 33950936 PMCID: PMC8104142 DOI: 10.1097/md.0000000000025591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/31/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Intravenous immunoglobulin (IVIg) is currently used with considerable success for the treatment of many autoimmune diseases, including systemic lupus erythematosus (SLE). Among its various indications, IVIg has also been found to be beneficial in myocarditis, whether or not it is associated with an autoimmune disease. Nevertheless, data regarding IVIg treatment for myocarditis/cardiomyopathy in patients with SLE are sparse. The objective of this case series was to describe our experience with IVIg as a treatment for lupus myocarditis and to review the literature for IVIg for this indication. PATIENT CONCERNS We report 5 female patients with SLE, who presented with signs of acute heart failure including pulmonary congestion and arrhythmias. DIAGNOSIS Echocardiography demonstrated new reduced left ventricular ejection fraction of 20% to 30%. Two patients underwent coronary artery angiography, which demonstrated normal coronary arteries, supporting the diagnosis of myocarditis or nonischemic cardiomyopathy. INTERVENTIONS High-dose IVIg treatment was initiated in all 5 patients. OUTCOMES Following the treatment, clinical and echocardiographic improvement in cardiac function occurred within a few days to 1 month. This dramatic improvement persisted for several years. CONCLUSION Based on our case series, we believe that IVIg has an important role in the management of lupus acute cardiomyopathy. This safe, well-tolerated optional treatment should be considered, especially in severe cases.
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Affiliation(s)
- Katya Meridor
- Department of Internal Medicine E, Meir Medical Center, Kfar Saba
- Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel HaShomer
- Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Oshrat Tayer-Shifman
- Rheumatology Unit, Meir Medical Center, Kfar Saba
- Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Levy
- Department of Internal Medicine E, Meir Medical Center, Kfar Saba
- Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Smith C, Guglin M, Dougherty RE, Rao RA. A Unique Case of Systemic Lupus Erythematosus Myocarditis Complicated by Plasmapheresis-Responsive Cardiogenic Shock. JACC Case Rep 2020; 2:2376-2380. [PMID: 34317175 PMCID: PMC8304555 DOI: 10.1016/j.jaccas.2020.09.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 11/25/2022]
Abstract
A 25-year-old woman with systemic lupus erythematosus complicated by biventricular failure with a history of multiple admissions presented with cardiogenic shock unresponsive to steroids, intravenous immunoglobulin, cyclophosphamide, and required extra-corporeal membrane oxygenation. Left ventricular function eventually recovered after plasmapheresis. (Level of Difficulty: Advanced.)
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Affiliation(s)
- Carson Smith
- Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Maya Guglin
- Division of Cardiology, Krannert Institute of Cardiology at Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel E Dougherty
- Department of Pathology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Roopa A Rao
- Division of Cardiology, Krannert Institute of Cardiology at Indiana University School of Medicine, Indianapolis, Indiana, USA
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16
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Systemic Lupus Erythematosus, Its Impact on Selected Cardiovascular Risk Factors, and Correlation with Duration of Illness: A Pilot Study. Cardiol Res Pract 2020; 2020:7025329. [PMID: 33204527 PMCID: PMC7665909 DOI: 10.1155/2020/7025329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 07/20/2020] [Accepted: 10/20/2020] [Indexed: 12/22/2022] Open
Abstract
Systemic lupus erythematosus is a rare autoimmune disease. It leads to an increased production of proinflammatory molecules that accelerates atherogenesis and could cause an endothelium dysfunction. The aim of the study was to assess cardiovascular risk factors such as BMI and lipid profile as well as left ventricular ejection fraction among patients with SLE, and a correlation of these factors with duration of the disease. Materials and Methods. The researched group consisted of patients with SLE, being under control of the outpatient clinic of cardiology. This group included 38 patients among whom 34 were women (56.17 ± 11.05 years) and 4 were men (65.50 ± 9.22 years). The control group consisted of 19 healthy women (53.31 ± 11.94 years) and 2 healthy men (38.51 ± 7.53 years). Measurements were taken in the same conditions by trained medical staff. Results. Excessive body weight (BMI >25 kg/m2) was more frequent in the SLE group, but it was not statistically significant (55.26% vs. 52.38%, p = 0.6159). LVEF values were lower in their searched group, and this factor showed statistical significance (53.92% ± 6.46 vs. 58.67% ± 4.69, p = 0.0044). Thickness of the IMT was higher and statistically important among patients with SLE, both in left (1.22 ± 0.27 mm vs. 0.7 ± 0.21 mm, p = 0.0001) and right common carotid artery (1.16 ± 0.26 mm vs. 0.59 ± 0.15 mm, p = 0.0001), compared to the controls. Conclusions. Patients with SLE are at greater risk of developing cardiovascular diseases as the illness progresses. The activity of the disease according to the SLEDAI-2K scale may have an impact on the LVEF values which was significantly decreased in the group with active disease, but further thorough investigation is required to fully evaluate the impact of individual components of the disease and its treatment on the CVD development and mortality.
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Abstract
Lupus myocarditis is a serious, potentially deadly disease. When it presents as an acute or fulminant myocarditis in a patient without an established diagnosis of lupus, lupus as an etiology of the condition is not commonly suspected. Meanwhile, it has a distinct treatment which may be lifesaving. Review of the literature can shed more light as current management is mostly based on clinical experience and case reports rather than randomized control trials. In this review we are discussing this diagnostic entity, focusing on cardiogenic shock as a manifestation of lupus myocarditis, and discussing management including aggressive immunosuppression, mechanical circulatory support, and cardiac transplantation.
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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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Butt S, Kiran S, Qadir N, Menghani D, Tanzeem H. Cardiac Conduction Defects in Systemic Lupus Erythematosus. Cureus 2020; 12:e10882. [PMID: 33178534 PMCID: PMC7652344 DOI: 10.7759/cureus.10882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Shayan Butt
- Internal Medicine, Baptist Memorial Hospital, Oxford, USA
| | - Simra Kiran
- Pulmonology and Critical Care, University of Cincinnati Medical Center, Cincinnati, USA
| | - Nida Qadir
- Infectious Diseases, University of Louisville, Louisville, USA
| | - Divya Menghani
- Infectious Diseases, University of Louisville, Louisville, USA
| | - Hammad Tanzeem
- Medicine, Dow Medical College/Civil Hospital, Karachi, PAK
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20
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Piranavan P, Perl A. Management of cardiovascular disease in patients with systemic lupus erythematosus. Expert Opin Pharmacother 2020; 21:1617-1628. [PMID: 32511034 PMCID: PMC7451028 DOI: 10.1080/14656566.2020.1770227] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/13/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION SLE is increasingly recognized as an important risk factor for cardiovascular disease. Premature CAD and several other cardiac manifestations are resulting in significant morbidity and premature death among young and older adults. There is a considerable unmet need for developing specific guidelines toward the primary and secondary prevention of cardiovascular disease in SLE patients. AREAS COVERED The authors describe the prevalence of various cardiovascular manifestations, associated with traditional and lupus-specific risk factors. They summarize the evidence behind various nonpharmacological and pharmacological options such as cardiac medications, antimalarials, anti-inflammatory, and immunosuppressant medications. EXPERT OPINION There is considerable literature claiming that the traditional Framingham score used to calculate the risk in the general population would not clearly predict the 10-year risk among SLE patients as they do not include lupus-specific risk factors such as accelerated inflammation, immunometabolic changes, thrombosis, vasospasm, vasculitis, and endothelial dysfunction into account. Identifying potential risk factors among SLE patients and treating hyperlipidemia regardless of their risk scores may be the first step in reducing mortality. Blocking lupus-specific inflammatory pathways by targeting validated biomarkers of pathogenesis has great future potential and more studies are needed on their cardiovascular benefits.
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Affiliation(s)
- Paramarjan Piranavan
- Department of Medicine, State University of New York, College of Medicine, Syracuse, New York 13210, USA
| | - Andras Perl
- Department of Medicine, State University of New York, College of Medicine, Syracuse, New York 13210, USA
- Department of Microbiology and Immunology, State University of New York, College of Medicine, Syracuse, New York 13210, USA
- Department of Biochemistry and Molecular Biology, State University of New York, College of Medicine, Syracuse, New York 13210, USA
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21
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Liu L, Dong Y, Gao H, Yao D, Zhang R, Zheng T, Jin Y, Lv B, Tian Y. Cardiogenic shock as the initial manifestation of systemic lupus erythematosus. ESC Heart Fail 2020; 7:1992-1996. [PMID: 32515553 PMCID: PMC7373915 DOI: 10.1002/ehf2.12806] [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: 01/14/2020] [Revised: 04/22/2020] [Accepted: 05/14/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiogenic shock as the initial manifestation of systemic lupus erythematosus (SLE) is an uncommon but catastrophic complication. Because of the lack of typical clinical features, the diagnosis of the disease is challenging. This case report describes a 47‐year‐old female admitted to the emergency room in refractory cardiogenic shock with dilative cardiomyopathy and a left ventricular ejection fraction (LVEF) of 25.6% of unknown origin. The patient responded poorly to the initial tries of stabilization, and the clinical status continued to deteriorate. Venous–arterial extracorporeal membrane oxygenation (V‐A ECMO) was applied to maintain hemodynamic stability. Coronary angiography revealed no obvious stenosis of the coronary artery. Evidence of virus infection was negative. After requestioning about medical history in detail, Reynaud's phenomenon was shown. SLE was suspected. A complete autoimmune laboratory workup was completed and found the positive result of antinuclear antibodies, anti‐double‐stranded DNA antibodies, anti‐phospholipid antibodies, and low C3 and C4. The patient also presented with pericardial effusion and the PLTs <100 000/mm3. SLE was confirmed according to the 2019 EULAR/ACR criteria. When the diagnosis was established, the immunotherapy was initiated. As a result, the patient underwent a quick recovery and achieved good outcomes. In conclusion, early diagnosis and timely application of immunotherapy is the key to treatment lupus myocarditis. Advanced mechanical support may play a necessary role when patient is in critical situation. For middle‐aged female patients presenting with unexplained cardiogenic shock, lupus myocarditis should be considered in the differential diagnosis. In addition, the 2019 EULAR/ACR criteria provide a new, fitting tool for the diagnosis, which is conducive to the earlier and more accurate diagnosis of SLE.
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Affiliation(s)
- Liang Liu
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Yanling Dong
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Hengbo Gao
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Dongqi Yao
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Rui Zhang
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Tuokang Zheng
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Yingli Jin
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Baopu Lv
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
| | - Yingping Tian
- Emergency Department, Second Hospital of Hebei Medical University, No.215 Heping West Road, Xinhua District, Shijiazhuang, Hebei, 050051, China
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22
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Xing ZX, Yu K, Yang H, Liu GY, Chen N, Wang Y, Chen M. Successful use of plasma exchange in fulminant lupus myocarditis coexisting with pneumonia: A case report. World J Clin Cases 2020; 8:2056-2065. [PMID: 32518801 PMCID: PMC7262706 DOI: 10.12998/wjcc.v8.i10.2056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/21/2020] [Accepted: 04/17/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Fulminant lupus myocarditis is a rare but fatal manifestation of systemic lupus erythematosus. Aggressive immunosuppressive treatments are important in its successful management. However, they can significantly damage the immunity and are associated with a considerable risk of infection development and spread. We present a rare and complicated case of a 20-year-old female diagnosed with fulminant lupus myocarditis accompanied by pneumonia. The patient was successfully treated with plasma exchange (PE) for fulminant lupus myocarditis.
CASE SUMMARY A 20-year-old Chinese woman presented to the Hematology Department complaining of fatigue and knee pain. Blood test showed anemia and thrombocytopenia. On the second day of hospitalization, she was transferred to the ICU due to dyspnea and hypotension. Autoimmune profiles showed hypocomplementemia and positive antinuclear antibodies. Computer tomography showed an enlarged heart and pneumonia. Ultrasound revealed an enlarged heart with a low left ventricular ejection fraction. Fulminant lupus myocarditis with cardiogenic shock was initially considered. Due to the accompanying pneumonia, aggressive immunosuppression was contraindicated. Her cardiac function remained critical after the initial therapy of intravenous immunoglobulin and corticosteroids at a conventional dose, but she responded well to later PE therapy plus corticosteroids administration. The patient fully recovered with normal cardiac function.
CONCLUSION This case indicates that PE is a valuable treatment choice without adverse effects of immunosuppression in patients with fulminant lupus myocarditis and coexisting infection.
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Affiliation(s)
- Zhou-Xiong Xing
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Kun Yu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Hang Yang
- Department of Anesthesiology, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Guo-Yue Liu
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Ni Chen
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Yong Wang
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
| | - Miao Chen
- Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, Guizhou Province, China
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23
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Dhooria A, Gawalkar A, Santosh K, Bahl A, Mb A, Naidu G, Sharma S, Sharma A, Jain S, Dhir V. Acute myocardial dysfunction in lupus: outcomes in Asian Indians. Clin Rheumatol 2020; 39:3661-3667. [PMID: 32445088 DOI: 10.1007/s10067-020-05177-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 05/07/2020] [Accepted: 05/15/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acute myocardial dysfunction is an uncommon but potentially fatal complication in systemic lupus erythematosus (SLE). We describe the outcome in a small series of Asian Indian patients and examine associated factors. METHODS SLE patients who fulfilled the 2012 SLICC criteria and developed new-onset myocardial dysfunction were included in this retrospective case series. Acute myocardial dysfunction was defined as global hypokinesia and left ventricular ejection fraction (LVEF)<50% on echocardiography (with or without symptoms) in patients with SLE. Survival was assessed using Kaplan-Meier survival analysis and Cox regression. RESULTS This study included 37 patients with mean age 28.2 ± 11.2 years and median (range) LVEF of 35% (18-48%) at presentation. A majority had active disease, with SLEDAI-2k ≥ 5 in 26 (of 28). All patients received oral corticosteroids and a majority received additional immunosuppression, including pulse methylprednisolone in 28 and cyclophosphamide in 27. Nine patients died during hospitalisation (25%), a majority due to infections. Death was significantly associated with elevated procalcitonin at presentation (p = 0.05), elevated white cell count (p = 0.02) and low complement C3 (p = 0.03). In those who survived, long-term outcomes were good, with complete myocardial recovery in 14 (64%). A higher ejection fraction at presentation was associated with complete recovery. CONCLUSIONS In this small series of patients of SLE with acute myocardial dysfunction, we report a significant in-hospital mortality due to infections. Many of the patients who died had elevated procalcitonin at presentation. A diligent search for infection seems prudent in lupus patients who present with acute myocardial dysfunction. Key Points • In patients of SLE with acute myocardial dysfunction who were treated with immunosuppression, there was significant short-term mortality due to infections. • This mortality was associated with elevated procalcitonin at baseline and may suggest some of them had pre-existing hidden sepsis. • A prudent search for infections in these patients before immunosuppression may help to decrease short-term mortality.
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Affiliation(s)
- Aadhaar Dhooria
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Atit Gawalkar
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Krishna Santosh
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Ajay Bahl
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Adarsh Mb
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Gsrsnk Naidu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shefali Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sanjay Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Varun Dhir
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
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Mavrogeni SI, Markousis-Mavrogenis G, Aggeli C, Tousoulis D, Kitas GD, Kolovou G, Iliodromitis EK, Sfikakis PP. Arrhythmogenic Inflammatory Cardiomyopathy in Autoimmune Rheumatic Diseases: A Challenge for Cardio-Rheumatology. Diagnostics (Basel) 2019; 9:diagnostics9040217. [PMID: 31835542 PMCID: PMC6963646 DOI: 10.3390/diagnostics9040217] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/04/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022] Open
Abstract
Ventricular arrhythmia (VA) in autoimmune rheumatic diseases (ARD) is an expression of autoimmune inflammatory cardiomyopathy (AIC), caused by structural, electrical, or inflammatory heart disease, and has a serious impact on a patient’s outcome. Myocardial scar of ischemic or nonischemic origin through a re-entry mechanism facilitates the development of VA. Additionally, autoimmune myocardial inflammation, either isolated or as a part of the generalized inflammatory process, also facilitates the development of VA through arrhythmogenic autoantibodies and inflammatory channelopathies. The clinical presentation of AIC varies from oligo-asymptomatic presentation to severe VA and sudden cardiac death (SCD). Both positron emission tomography (PET) and cardiovascular magnetic resonance (CMR) can diagnose AIC early and be useful tools for the assessment of therapies during follow-ups. The AIC treatment should be focused on the following: (1) early initiation of cardiac medication, including ACE-inhibitors, b-blockers, and aldosterone antagonists; (2) early initiation of antirheumatic medication, depending on the underlying disease; and (3) potentially implantable cardioverter–defibrillator (ICD) and/or ablation therapy in patients who are at high risk for SCD.
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Affiliation(s)
- Sophie I. Mavrogeni
- Onassis Cardiac surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.K.)
- Correspondence:
| | | | - Constantina Aggeli
- First Cardiac Clinic, Hippokration University Hospital, 17674 Athens, Greece; (C.A.); (D.T.)
| | - Dimitris Tousoulis
- First Cardiac Clinic, Hippokration University Hospital, 17674 Athens, Greece; (C.A.); (D.T.)
| | - George D. Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester M13 9PT, UK;
| | - Genovefa Kolovou
- Onassis Cardiac surgery Center, 17674 Athens, Greece; (G.M.-M.); (G.K.)
| | | | - Petros P. Sfikakis
- First Department of Propeudeutic and Internal medicine, Laikon Hospital, Athens University Medical School, 17674 Athens, Greece;
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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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Perel-Winkler A, Bokhari S, Perez-Recio T, Zartoshti A, Askanase A, Geraldino-Pardilla L. Myocarditis in systemic lupus erythematosus diagnosed by 18F-fluorodeoxyglucose positron emission tomography. Lupus Sci Med 2018; 5:e000265. [PMID: 30094040 PMCID: PMC6069920 DOI: 10.1136/lupus-2018-000265] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/24/2018] [Accepted: 06/12/2018] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Alexandra Perel-Winkler
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Sabahat Bokhari
- Division of Cardiology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
- Nuclear Cardiology Laboratory, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Thania Perez-Recio
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Afshin Zartoshti
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Anca Askanase
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
| | - Laura Geraldino-Pardilla
- Division of Rheumatology, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York City, New York, USA
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Hawkins AM, Jesuthasan LSB, Vardesh DL. Case of severe acute lupus myocarditis and multiple-organ failure. BMJ Case Rep 2018; 2018:bcr-2018-225085. [PMID: 29925558 DOI: 10.1136/bcr-2018-225085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
We report a case of severe lupus myocarditis with rapid, acute deterioration to cardiogenic shock and multiorgan failure, highlighting the importance of early identification and treatment of acute presentations in patients with systemic lupus erythematosus. A 31-year-old woman with previously diagnosed subacute cutaneous lupus erythematosus initially presented with abdominal pain and frank per-rectal bleeding. She deteriorated rapidly with type 1 respiratory failure and acute kidney injury requiring dialysis secondary to acute cardiac failure with a prolonged intensive care unit admission, over a month. A significantly elevated troponin, global hypokinesia on echocardiogram and normal coronary artery angiogram and cardiac MRI lead to the diagnosis of acute lupus myocarditis as the cause for the cardiogenic shock. She was treated with high-dose corticosteroids and eventually made a full recovery, with cardiac function returning to normal.
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Affiliation(s)
- Aaron M Hawkins
- Department of Medicine, Logan Hospital, Meadowbrook, Queensland, Australia.,School of Medicine, Griffith University, Southport, Queensland, Australia
| | | | - Deepak L Vardesh
- Department of Medicine, Logan Hospital, Meadowbrook, Queensland, Australia.,School of Medicine, Griffith University, Southport, Queensland, Australia
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Tanwani J, Tselios K, Gladman DD, Su J, Urowitz MB. Lupus myocarditis: a single center experience and a comparative analysis of observational cohort studies. Lupus 2018; 27:1296-1302. [PMID: 29642752 DOI: 10.1177/0961203318770018] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Lupus myocarditis (LM) is reported in 3-9% of patients with systemic lupus erythematosus (SLE) but limited evidence exists regarding optimal treatment and prognosis. This study aims to describe LM in a defined lupus cohort as compared with the existing literature. Patients and methods Patients with LM were identified from the University of Toronto Lupus Clinic database. Diagnosis was based on clinical manifestations and electrocardiographic, imaging, and biochemical criteria. Demographic, clinical, diagnostic and therapeutic variables and outcomes were collected in a standardized data retrieval form. A literature review was performed to identify cohort studies reporting on LM treatment and outcome. A comparative analysis was conducted between our patients and the combined cohort of the existing studies. Results Thirty patients were diagnosed with LM (prevalence 1.6%) and compared with a cumulative cohort of 117 patients from five distinct studies. No significant differences were found regarding the age at diagnosis (32.6 ± 13.4 years) and SLE duration (2.5 years median). Concomitant lupus activity from other organ systems was observed in 97% of the patients. Chest pain was more frequently reported in our cohort whereas dyspnea was more prominent in the other studies. Diagnostic criteria were similar across studies. Therapeutic approach was comparable and consisted of glucocorticosteroids (96.6%) and immunosuppressives (70%). Mortality was approximately 20% whereas another 20% of the patients achieved partial and 60% complete recovery. Conclusions LM usually occurs early in the disease course and in the context of generalized lupus activity. Despite aggressive therapy, approximately 40% of the patients died or had residual heart damage.
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Affiliation(s)
- J Tanwani
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - K Tselios
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - D D Gladman
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - J Su
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
| | - M B Urowitz
- University of Toronto Lupus Clinic, Centre of Prognosis Studies in the Rheumatic Diseases, University Health Network, Toronto, Canada
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Tariq S, Garg A, Gass A, Aronow WS. Myocarditis due to systemic lupus erythematosus associated with cardiogenic shock. Arch Med Sci 2018; 14:460-462. [PMID: 29593821 PMCID: PMC5868675 DOI: 10.5114/aoms.2017.68692] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 11/04/2015] [Indexed: 12/18/2022] Open
Affiliation(s)
- Sohaib Tariq
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Anjali Garg
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Alan Gass
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Wilbert S Aronow
- Cardiology Division, Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
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30
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Saraca LM, Lazzari L, di Giuli C, Lavagna A, Mezzetti P, Bovelli D, Boschetti E, Francisci D. Cytomegalovirus myocarditis in a patient with systemic lupus erythematosus (SLE) successfully treated with ganciclovir. IDCases 2018; 12:4-6. [PMID: 29850400 PMCID: PMC5966621 DOI: 10.1016/j.idcr.2018.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 12/25/2022] Open
Abstract
Myocarditis is an inflammatory disease of the myocardium. Viruses, such as enterovirus, adenovirus, parvovirus B19, HHV6 or cytomegalovirus (CMV) and autoimmune diseases are recognized causes of myocarditis. We describe the clinical case of a young Indian woman with SLE and a concomitant acute CMV related myocarditis with favourable outcome after ganciclovir therapy. CMV myocarditis may range from being a subclinical infection with incidental findings on ECG to a life threating presentation. There are no trials demonstrating the efficacy of antiviral therapy in myocarditis. Case series of patients with CMV myocarditis have reported an excellent clinical outcome after antiviral agents. Lupus Myocarditis (LM) is more prevalent in young females. There are no specific ECG or echocardiographic signs. Treatment strategies of LM are based on corticosteroids, immunosuppressive agents and cardiovascular support, usually with a favorable prognosis, but LM often lead to a severe clinical picture, with mortality of 10.3%. Endomyocardial biopsy (EBM) is recommended as the gold standard but it is very underused in clinical practice, It should be performed in a specialized center but there are concerns on lack of specificity, low negative predictive value, risk of complication, and sampling errors due to the focal nature of myocarditis. Both SLE and CMV are potentially responsible of acute myocarditis. In our knowledge, CMV myocarditis with SLE was described in only one other patient. The initiation of antiviral therapy improved the clinical picture and, in our opinion, it is mandatory when CMV related life threating conditions develop.
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Affiliation(s)
- Lavinia Maria Saraca
- Infectious Diseases Clinic, University Hospital “S. Maria”, University of Perugia, Terni, Italy
| | - Ludovico Lazzari
- Department of Cardiology, University Hospital “S. Maria”, University of Perugia, Terni, Italy
| | - Cinzia di Giuli
- Infectious Diseases Clinic, University Hospital “S. Maria”, Terni, Italy
| | - Alessandro Lavagna
- Infectious Diseases Clinic, University Hospital “S. Maria”, Terni, Italy
| | - Paola Mezzetti
- Department of Cardiology, University Hospital “S. Maria”, Terni, Italy
| | - Daniela Bovelli
- Department of Cardiology, University Hospital “S. Maria”, Terni, Italy
| | - Enrico Boschetti
- Department of Cardiology, University Hospital “S. Maria”, University of Perugia, Terni, Italy
| | - Daniela Francisci
- Infectious Diseases Clinic, University Hospital “S. Maria”, University of Perugia, Terni, Italy
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Wang CR, Tsai YS, Li WT. Lupus myocarditis receiving the rituximab therapy-a monocentric retrospective study. Clin Rheumatol 2018; 37:1701-1707. [PMID: 29299707 DOI: 10.1007/s10067-017-3971-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/22/2017] [Accepted: 12/22/2017] [Indexed: 01/11/2023]
Abstract
Despite high-dose corticosteroids alone or with immunosuppressive agents as the standard therapy in lupus myocarditis (LM), an immune complex-mediated critical setting, such management is still associated with resistant disease and even mortality. A retrospective study was performed for the refractory LM patients treated with rituximab (RTX), a very limited experience in English literatures. A retrospective review of the myocarditis manifestation was carried out in hospitalized Han Chinese patients with SLE from February 2007 to January 2017. This study analyzed lupus patients who met the diagnosis of LM for their demographic, clinical, laboratory, and radiological data including cardiac magnetic resonance imaging and echocardiography as well as the medication profiles. Among 802 SLE patients, 13 female (1.6%) aged 19 to 52 years (31.9 ± 10.7), fulfilled the LM diagnostic criteria. Under the indications of LM or multi-organic flares with myocarditis refractory to the conventional therapy, three cases received the RTX therapy. All had improved myocardial function as demonstrated by clinical and imaging presentations as well as a decrease in lupus activity. In this 10-year retrospective monocentric cohort, improved myocardial function is demonstrated in refractory LM patients receiving the RTX therapy.
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Affiliation(s)
- Chrong-Reen Wang
- Section of Rheumatology, Department of Internal Medicine, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan, 70403, Taiwan.
| | - Yi-Shan Tsai
- Department of Radiology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Wei-Ting Li
- Section of Critical Care Medicine, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
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Xu D, Zhao RC, Gao WH, Cui HB. A Risk Prediction Model for In-hospital Mortality in Patients with Suspected Myocarditis. Chin Med J (Engl) 2017; 130:782-790. [PMID: 28345541 PMCID: PMC5381311 DOI: 10.4103/0366-6999.202747] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background: Myocarditis is an inflammatory disease of the myocardium that may lead to cardiac death in some patients. However, little is known about the predictors of in-hospital mortality in patients with suspected myocarditis. Thus, the aim of this study was to identify the independent risk factors for in-hospital mortality in patients with suspected myocarditis by establishing a risk prediction model. Methods: A retrospective study was performed to analyze the clinical medical records of 403 consecutive patients with suspected myocarditis who were admitted to Ningbo First Hospital between January 2003 and December 2013. A total of 238 males (59%) and 165 females (41%) were enrolled in this study. We divided the above patients into two subgroups (survival and nonsurvival), according to their clinical in-hospital outcomes. To maximize the effectiveness of the prediction model, we first identified the potential risk factors for in-hospital mortality among patients with suspected myocarditis, based on data pertaining to previously established risk factors and basic patient characteristics. We subsequently established a regression model for predicting in-hospital mortality using univariate and multivariate logistic regression analyses. Finally, we identified the independent risk factors for in-hospital mortality using our risk prediction model. Results: The following prediction model for in-hospital mortality in patients with suspected myocarditis, including creatinine clearance rate (Ccr), age, ventricular tachycardia (VT), New York Heart Association (NYHA) classification, gender and cardiac troponin T (cTnT), was established in the study: P = ea/(1 + ea) (where e is the exponential function, P is the probability of in-hospital death, and a = −7.34 + 2.99 × [Ccr <60 ml/min = 1, Ccr ≥60 ml/min = 0] + 2.01 × [age ≥50 years = 1, age <50 years = 0] + 1.93 × [VT = 1, no VT = 0] + 1.39 × [NYHA ≥3 = 1, NYHA <3 = 0] + 1.25 × [male = 1, female = 0] + 1.13 × [cTnT ≥50 μg/L = 1, cTnT <50 μg/L = 0]). The area under the receiver operating characteristic curve was 0.96 (standard error = 0.015, 95% confidence interval [CI]: 0.93-0.99). The model demonstrated that a Ccr <60 ml/min (odds ratio [OR] = 19.94, 95% CI: 5.66–70.26), an age ≥50 years (OR = 7.43, 95% CI: 2.18–25.34), VT (OR = 6.89, 95% CI: 1.86–25.44), a NYHA classification ≥3 (OR = 4.03, 95% CI: 1.13–14.32), male gender (OR = 3.48, 95% CI: 0.99–12.20), and a cTnT level ≥50 μg/L (OR = 3.10, 95% CI: 0.91–10.62) were the independent risk factors for in-hospital mortality. Conclusions: A Ccr <60 ml/min, an age ≥50 years, VT, an NYHA classification ≥3, male gender, and a cTnT level ≥50 μg/L were the independent risk factors resulting from the prediction model for in-hospital mortality in patients with suspected myocarditis. In addition, sufficient life support during the early stage of the disease might improve the prognoses of patients with suspected myocarditis with multiple risk factors for in-hospital mortality.
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Affiliation(s)
- Duo Xu
- Department of Cardiology, Ningbo First Hospital, Ningbo, Zhejiang 315010; Department of Cardiology, CHC International Hospital, Cixi, Zhejiang 315310, China
| | - Ruo-Chi Zhao
- Department of Cardiology, Ningbo First Hospital, Ningbo, Zhejiang 315010, China
| | - Wen-Hui Gao
- Department of Cardiology, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang 315100, China
| | - Han-Bin Cui
- Department of Cardiology, Ningbo First Hospital, Ningbo, Zhejiang 315010, China
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33
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Charhon N, Bernard C, Richard JC, Cordel N, Leboucher G, Broussolle C, Sève P. [Off-label use of intravenous immunoglobulin therapy in the treatment of lupus myocarditis: Two case reports and literature review]. Rev Med Interne 2016; 38:204-209. [PMID: 27263120 DOI: 10.1016/j.revmed.2016.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 03/14/2016] [Accepted: 05/02/2016] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Several case reports have reported the benefit of intravenous immunoglobulin therapy in many autoimmune diseases, including systemic lupus erythematosus. CASE REPORTS Here, we report on two cases of lupus myocarditis treated with high dose of intravenous immunoglobulin. The first patient was a 42-year-old woman who presented with lupus myocarditis that was resistant to corticosteroids and cyclophosphamide, and who was finally successfully treated with a single dose of 2 g/kg of intravenous immunoglobulin. The patient displayed clinical improvement a few days later. The second case - a 43-year-old woman was diagnosed with lupus myocarditis and immunosuppressive drugs were contraindicated because of the context of a recent infective endocarditis. She was treated with repeated dose of 2 g/kg of intravenous immunoglobulin. Clinical improvement was observed and the left ventricular ejection fraction increased from 20 % to 60 % within a few days. We also report 9 similar observations identified from a literature review. CONCLUSION The use of intravenous immunoglobulin in lupus myocarditis is not officially recognized but could be considered as an alternative when conventional therapies have failed or are contraindicated.
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Affiliation(s)
- N Charhon
- Service pharmaceutique, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France.
| | - C Bernard
- Service de médecine interne, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - J C Richard
- Service de réanimation médicale et d'assistance respiratoire, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - N Cordel
- Unité de dermatologie-médecine interne, CHU Pointe-à-Pitre, route de Chauvel, BP 465, 97159 Pointe-à-Pitre cedex, France; EA 4546, université des Antilles, campus de Fouillole, BP 250, 97157 Pointe-à-Pitre, Guadeloupe
| | - G Leboucher
- Service pharmaceutique, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - C Broussolle
- Service de médecine interne, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
| | - P Sève
- Service de médecine interne, hôpital de la Croix-Rousse, hospices civils de Lyon, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
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Du Toit R, Herbst PG, van Rensburg A, du Plessis LM, Reuter H, Doubell AF. Clinical features and outcome of lupus myocarditis in the Western Cape, South Africa. Lupus 2016; 26:38-47. [PMID: 27225211 DOI: 10.1177/0961203316651741] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 04/20/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND African American ethnicity is independently associated with lupus myocarditis compared with other ethnic groups. In the mixed racial population of the Western Cape, South Africa, no data exists on the clinical features/outcome of lupus myocarditis. OBJECTIVES The objective of this study was to give a comprehensive description of the clinical features and outcome of acute lupus myocarditis in a mixed racial population. METHODS Clinical records (between 2008 and 2014) of adult systemic lupus erythematosus (SLE) patients at a tertiary referral centre were retrospectively screened for a clinical and echocardiographic diagnosis of lupus myocarditis. Clinical features, laboratory results, management and outcome were described. Echocardiographic images stored in a digital archive were reanalysed including global and regional left ventricular function. A poor outcome was defined as lupus myocarditis related mortality or final left ventricular ejection fraction (LVEF) <40%. RESULTS Twenty-eight of 457 lupus patients (6.1%) met inclusion criteria: 92.9% were female and 89.3% were of mixed racial origin. Fifty-three per cent of patients presented within three months after being diagnosed with SLE. Seventy-five per cent had severely active disease (SLE disease activity index ≥ 12) and 67.9% of patients had concomitant lupus nephritis. Laboratory results included: lymphopenia (69%) and an increased aRNP (61.5%). Treatment included corticosteroids (96%) and cyclophosphamide (75%); 14% of patients required additional immunosuppression including rituximab. Diastolic dysfunction and regional wall motion abnormalities occurred in > 90% of patients. LVEF improved from 35% to 47% (p = 0.023) and wall motion score from 1.88 to 1.5 (p = 0.017) following treatment. Overall mortality was high (12/28): five patients (17.9%) died due to lupus myocarditis (bimodal pattern). Patients who died of lupus myocarditis had a longer duration of SLE (p = 0.045) and a lower absolute lymphocyte count (p = 0.041) at diagnosis. LVEF at diagnosis was lower in patients who died of lupus myocarditis (p = 0.099) and in those with a persistent LVEF < 40% (n = 5; p = 0.046). CONCLUSIONS This is the largest reported series on lupus myocarditis. The mixed racial population had a similar prevalence, but higher mortality compared with other ethnic groups (internationally published literature). Patients typically presented with high SLE disease activity and the majority had concomitant lupus nephritis. Lymphopenia and low LVEF at presentation were of prognostic significance, associated with lupus myocarditis related mortality or a persistent LVEF < 40%.
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Affiliation(s)
- R Du Toit
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Tygerberg, Cape Town, South Africa
| | - P G Herbst
- Division Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Tygerberg, Cape Town, South Africa
| | - A van Rensburg
- Division Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Tygerberg, Cape Town, South Africa
| | - L M du Plessis
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Tygerberg, Cape Town, South Africa
| | - H Reuter
- Division of Rheumatology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Tygerberg, Cape Town, South Africa
| | - A F Doubell
- Division Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Academic Hospital, Tygerberg, Cape Town, South Africa
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