Right-sided heart failure in a 37-year-old man with systemic lupus erythematosus

Abstract

The patient was a 37-year-old male who sought medical assistance due to dyspnea even at rest, edema of the lower limbs, and fever.Five years earlier, after a period of fever and arthralgia, the diagnosis of systemic lupus erythematosus was established and for five years the patient had been using a special formulation containing 100mg of chloroquine, 6mg of deflazacort, 130mg of benzobromarone, 30mg of indomethacin, and 20mg of famotidine.After three years, appeared dyspnea on strenuous exertion , evolving to dyspnea on medium exertion, and, one year later, edema of the lower limbs and dry nocturnal cough appeared not accompanied by orthopnea. Since that time, the patient had been using 0.25mg of digoxin, 40mg of furosemide, 5mg of enalapril, and 200mg of theophylline.On physical examination (4/16/97), the patient's pulse was 80bpm, his blood pressure was 170/130mmHg in the right upper limb and 180/120mmHg in the right lower limb. The pulmonary examination was normal. The heart examination showed an increased intensity of the second cardiac sound in the pulmonary area. The liver was palpated 2cm from the right costal margin. Edema (+/4+) of the lower limbs was evident. Laboratory tests are shown in table I.An electrocardiogram (4/24/97) showed sinus rhythm, a heart rate of 87bpm, amplitude of the P wave of 0.3 mV, P axis +80° forward, QRS axis +120° backwards, sugestive of right atrial and ventricular hypertrophy ( fig. 1).An echocardiogram (4/24/97) showed an increased thickness of the interventricular septum and posterior wall of the left ventricle, normal left ventricular diameters, and normal left ventricular ejection fraction with no alteration in segmentary contractility. The diameter of the aorta was 35mm, the left atrial diameter was 36mm, and the right ventricle was dilated and hypokinetic with a systolic pressure of 110mmHg evaluated through Doppler. Mild mitral and moderate tricuspid regurgitations, and a mild pericardial effusion were evident.A few days later (5/7/97), the patient sought medical assistance because of worsening of the edema. On physical examination, the patient's pulse was 78bpm and his blood pressure was 140/100mmHg. The pulmonary examination was normal. A cardiac examination showed increased