2019 Research Forum

An Unusual Case of SLE-Induced-Pericarditis in a Young Hispanic Male

Jonathan Bowen MS IV 1,2 Fowrooz Joolhar MD 1

, Christina Donath MS IV 1,2

, Marwa Afridi MS IV 1,2

; Leila Moosavi MD R3 1

, Azadeh Ghassemi MS IV 1,2 ,

, Tiffany Win MD 1

1. Cardiology Department of Medicine, Kern Medical, Bakersfield, CA, United States 2. Ross University School of Medicine, Kern Medical, Bakersfield, CA, United States

Infectious & Autoimmune Workup

Introduction

Discussion

• Systemic Lupus Erythematosus (SLE) is an autoimmune disease that is four to twelve times more common in females than males. Widespread inflammation occurs due to the production of self-antibodies that target a variety of organ systems and tissues. Pericarditis is the most common cardiac complication; however, it is rare to be the initial presenting symptom in only 1% of documented cases. • Here we report a previously healthy young adult male with the unusual presentation of pericarditis as the initial manifesting symptom in SLE with multiple organ system involvement. • There is limited data to date of SLE in an young adult male with pericarditis as initial manifesting symptom when diagnosed and after extensive review of the literature we believe this is first case to date. 22-year-old Hispanic male with no past medical history presented to the ED with recent onset of 10/10 sharp upper extremity polyarticular joint pain. Patient stated it began 2-months prior to this presentation but began to worsen within last few days. Patients initial vitals were significant only for tachycardia. Lab work was significant for neutropenic leukocytosis, elevated ESR and CRP (See Tables 1-3). patient was given a single dose of tramadol and discharged home with Naproxen with the diagnosis of polyarthralgia despite vitals at discharge showing patient had become febrile and tachycardic since presentation. Patient returned within 48 hours with shortness of breath and pleuritic chest pain. Vitals showed fever had worsened, tachycardic, and now tachypneic (Table 1). Physical exam was significant for pericardial friction rub, crackles in bilateral lower lung fields, and bilateral wrists were edematous, tender to palpation with restricted range of motion due to pain bilaterally. Lab workup showed up trending neutropenic leukocytosis and elevated troponin-I. Blood cultures x2 obtained, started on broad spectrum antibiotics and IV fluids with a full infectious workup (Table 2) . EKG showed sinus tachycardia with diffuse ST elevation and PR depressions; Chest X-ray showed bilateral pleural effusions; CT was significant for pericardial effusion and bilateral pleural effusion. 2-D Echo was significant only for small pericardial effusion. Five hours later patient showed no signs of improvement which prompted a full autoimmune workup (Tables 3) . Patient was then started on Colchicine PO BID and Indomethacin PO TID to which patients symptoms and vitals improved and remained stable. Case Report

Conclusions ● Distinguishing between sepsis and acute exacerbation of SLE can be challenging in a patient without prior history of medical illness. ● Therefore, clinicians should have a high degree of suspicion for an autoimmune etiology when a healthy young male presents with a multiorgan involvement and symmetrical synovitis. References 1. Bezwada, P., Quadri, A., Shaikh, A., Ayala-Rodriguez, C., & Green, S. (2017). ● We hope to emphasize that an autoimmune disease such as SLE while 4-12x more common in women can present in young healthy males. To best of our knowledge this is the first case of SLE pericarditis in a young adult male as the initial manifesting symptom at diagnosis may have complicated the workup and evaluation. We also hope to emphasize the importance and improve the differential diagnosis when dealing with symmetrical polyarthritis in an otherwise healthy young male with multiorgan failure by including autoimmune etiologies as well as the usual suspects of STIs, viral causes, or malignancy. ● Over-all, the management of this patient on initial presentation overlooked several red flags that if thoroughly investigated would have prevented premature bounce-back, progression of symptoms, and a more conclusive differential diagnosis. Avoidance of bias from the stigmata of autoimmune diseases having a gender preference was crucial in this case. ● A thorough literature review shows that SLE pericarditis is commonly associated with synovitis and other serositis issues of bilateral pleural effusions and/or pericardial effusions, which both presented in this patient at time of diagnoses. Given the spectrum of complications of SLE, managing the systemic inflammatory response with medical management early is cost efficient and allows a more favorable prognosis.

Patient was initially worked up for infective pericarditis and met several criteria for Systemic Inflammatory Response Syndrome(SIRS). After Patient did not respond to broad spectrum antibiotics and anti-pyretic medications (Days 3-4). Autoimmune pericarditis was then suspected and patient was started on appropriate therapy leading to significant improvement in symptoms with downtrend of cardiac and inflammatory enzymes (Days 4-6).

Table 3: Autoimmune Work up

Table 2. Infectious Workup

Imaging

The imaging studies performed during the patient’s workup are significant for multi-organ involvement inflammation as an initial presentation of SLE with involvement of the serosa, lung, pericardium, and musculoskeletal system.

X-ray of L and R Hand significant for bilateral periarticular osteopenia and soft tissue swelling worse on the right hand.

CT Angiogram of the Chest shows 8mm pericardial effusion ( red arrow ) with moderate left pleural effusion and small right pleural effusion.

Chest X-ray - bilateral small pleural effusions or possible atelectasis.

Myopericarditis and Pericardial Effusion as the Initial Presentation of Systemic

Lupus Erythematosus. Case reports in medicine, 2017, 6912020.

Electrocardiogram (ECG) and Echocardiogram

2. McMechan, S. R., McClements, B. M., McKeown, P. P., Webb, S. W., & Adgey, A.

A

B

A. (1995). Systemic lupus erythematosus presenting as effuso-constrictive

SYSTOLE R

DIASTOLE R

pericarditis. Postgraduate medical journal , 71 (840), 627-9.

3. Tan, T. C., Fang, H., Magder, L. S., & Petri, M. A. (2012). Differences between

male and female systemic lupus erythematosus in a multiethnic population. The

LV VR

RV VR

PE

LV VR

Journal of rheumatology , 39 (4), 759-69.

RV VR

PE

LA VR

Table 1. Vital signs and WBC count Vital check interval between 3a-3b= 5 hours Vital check interval between 3c-3d= 5 hours ‡ IV antibiotics begun ∗ Naproxen began **Colchicine and Indomethacin started Ω IV antibiotics discontinued

4. Topaloglu, S., Aras, D., Ergun, K., Altay, H., Alyan, O., Akgul, A. (2006)

LA VR

RA

RA VR

Systemic lupus erythematosus: An unusual cause of cardiac tamponade in a young

man, European Journal of Echocardiography , 7 (1) 460–462

PE

PE

5. Zeller, C. B., & Appenzeller, S. (2008). Cardiovascular disease in systemic lupus

ECG on initial presentation demonstrating diffuse ST elevations with PR depressions pathognomonic for pericarditis. PR Depressions, ST elevations.

Echocardiogram performed during the hospital stay showing a small posterior pericardial effusion and small lateral pericardial effusion present in both diastole (A) and systole (B) without cardiac tamponade.

erythematosus: the role of traditional and lupus related risk factors. Current

cardiology reviews, 4(2), 116-22.

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