Concomitant new diagnosis of systemic lupus erythematosus and COVID-19 with possible antiphospholipid syndrome. Just a coincidence? A case report and review of intertwining pathophysiology

In the midst of the COVID-19 pandemic, further understanding of its complications points towards dysregulated immune response as a major component. Systemic lupus erythematosus (SLE) is also a disease of immune dysregulation leading to multisystem compromise. We present a case of new-onset SLE concomitantly with COVID-19 and development of antiphospholipid antibodies. An 18-year-old female that presented with hemodynamic collapse and respiratory failure, progressed to cardiac arrest, and had a pericardial tamponade drained. She then progressed to severe acute respiratory distress syndrome, severe ventricular dysfunction, and worsening renal function with proteinuria and hematuria. Further studies showed bilateral pleural effusions, positive antinuclear and antidouble-stranded DNA antibodies, lupus anticoagulant, and anticardiolipin B. C3 and C4 levels were low. SARS-Cov-2 PCR was positive after 2 negative tests. She also developed multiple deep venous thrombosis, in the setting of positive antiphospholipid antibodies and lupus anticoagulant. In terms of pathophysiology, COVID-19 is believed to cause a dysregulated cytokine response which could potentially be exacerbated by the shift in Th1 to Th2 response seen in SLE. Also, it is well documented that viral infections are an environmental factor that contributes to the development of autoimmunity; however, COVID-19 is a new entity, and it is not known if it could trigger autoimmune conditions. Additionally, it is possible that SARS-CoV-2, as it happens with other viruses, might lead to the formation of antiphospholipid antibodies, potentially contributing to the increased rates of thrombosis seen in COVID-19.

Dissolution of intracardiac mass lesions in the primary antiphospholipid antibody syndrome

The antiphospholipid antibody syndrome has numerous cardiac manifestations, including valvular thickening, insufficiency, and mass lesions. The mass lesions may be confused with atrial myxomas and other vegetations, sometimes necessitating a surgical diagnosis. There are no prospective studies on treatment or follow-up of intracardiac lesions in antiphospholipid antibody syndrome. We prospectively followed up three patients with antiphospholipid antibody syndrome for intracardiac lesions (one atrial and two mitral valve masses) complicated by systemic embolization. Anticoagulation led to complete resolution of the masses in 6 weeks to 3 months. We propose that initial treatment of an intracardiac lesion in patients with antiphospholipid antibody syndrome should be a trial of systemic anticoagulation before surgical intervention.