Pericarditis with cardiac tamponade in systemic lupus erythematosus. Development immediately following successful control of lupus flare
Sir,Pericarditis is a well-known complication of systemic lupus erythematosus (SLE). 1 In rare cases, large pericardial effusions causing hemodynamic compromise can result. [2][3][4][5] In patients of this kind, the response to medical therapy with aspiration is unpredictable, and surgical intervention may be required. 6,7 In this report, the clinical course of a patient, who developed pericarditis and tamponade despite successful medical therapy for a lupus flare, is described.A 32-year-old woman presented to the Emergency Department (ED) with increasing dyspnea of 24-h duration. She had a 4-year history of SLE with antiphospholipid antibody syndrome (APS). She had been anticoagulated following a pulmonary embolus 4 years previously, but had recently defaulted on coumadin therapy. A contrast-enhanced spiral computerized tomography (CT) scan performed in the ED identified acute bilateral pulmonary emboli. An insignificant pericardial effusion was also noted, and confirmed at echocardiography. Subcutaneous enoxaparin 1 mg/kg/day was administered and the patient was hospitalized. Several days later she developed a diffuse macular rash on her extremities. Urinalysis revealed abundant red cells with >300 mg% proteinuria, Serum creatinine increased acutely from 1.1 to 2.6 mg/dl. Complement C3 and C4 levels were low at 36 and <1 mg/dl, respectively. Methylprednisolone 1 g was administered intravenously for 3 days, followed by prednisone 60 mg once daily orally, with oral mycophenolate mofetil 500 mg twice daily. The patient exhibited an excellent response, with resolution of rash, decreased proteinuria (to 100 mg%), and normalization of creatinine within 5 days. Six days later she developed recurrent dyspnea with chest pain. Physical examination revealed sinus tachycardia, hypotension and pulsus paradoxus. Repeat echocardiography demonstrated a massive pericardial effusion with signs of cardiac tamponade (Figure 1A).
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