A Rare Case of Malignant Mesothelioma Presenting with Systemic Lupus Erythematosus Seropositivity: A Case Report and Review of Literature

Abstract

While malignant mesothelioma may initially present in a variety of ways, it is uncommon to present with systemic lupus erythematosus (SLE) seropositivity and thus obscuring its diagnosis. Our case involves a 75-year-old Caucasian male with a past medical history of essential hypertension, remote prostate cancer status post prostatectomy, and lifetime nontobacco use presenting with progressive shortness of breath over one month. After a negative cardiac assessment, a postcardiac catheterization chest X-ray (CXR) revealed a right-sided moderate-to-large pleural effusion that, on further workup, was found to be exudative. Effusion studies were negative for malignancy and bacterial growth. Recurrent accumulation of fluid after a thoracentesis one week prior prompted an autoimmune work up. Positive markers included antinuclear antibodies, anti-double stranded DNA antibodies, and anti-histone antibodies, while anti-Smith antibodies were negative. Although SLE was initially suspected based on serologies, no clinical signs or symptoms were present to fulfill the diagnosis criteria. A trial of oral prednisone resulted in decreased pleural effusion size with no further recurrence. Additional studies included a CT scan of the chest that showed pleural masses confirmed with biopsy to be epithelioid mesothelioma. Given the patient’s age and new diagnosis of malignant mesothelioma, we hypothesized that the presence of autoantibodies was likely false positives due to acquired autoantibodies with age, hyperactivity of the immune system from malignancy, and possible prior asbestos exposure.

A Case Report of Pericardial Effusion with False-Positive Mesothelioma and Adenocarcinoma Markers as the Initial Presentation of Systemic Lupus Erythematous

“…While a handful of case studies have described patients with SLE presenting with pericardial efusion positive for mesothelial cell markers, all described patients were ultimately diagnosed with mesothelioma [12][13][14][15], consistent with the high sensitivity and specifcity of mesothelioma markers. Importantly, the patients' efusions in these studies were not controlled long-term with immunosuppressives, whereas our patient's efusion has not recurred with management of her SLE.…”

“…Positive mesothelioma markers (including calretinin and CK 5/6) in the effusion cytology, in addition to pleural or pericardial masses on CT chest imaging prompted obtaining biopsies, which confirmed the diagnosis of malignant mesothelioma in each case. While two of the patients' effusions initially improved on steroid therapy intended to treat the initial diagnosis [ 12 , 14 ], all four patients failed chemotherapy and ultimately died of malignant mesothelioma.…”

“…Even rarer is the presentation of malignant mesothelioma as SLE. Since 1984, there have been at least four case reports documenting malignant mesothelioma that initially presented and were diagnosed as SLE due to pleural efusion or pericardial efusion combined with clinical features of SLE or positive antibodies [12][13][14][15]. Positive mesothelioma markers (including calretinin and CK 5/6) in the efusion cytology, in addition to pleural or pericardial masses on CT chest imaging prompted obtaining biopsies, which confrmed the diagnosis of malignant mesothelioma in each case.…”

Minimal Change Disease Associated with Malignant Epithelioid Mesothelioma: A Case Report

“…Malignancy itself, triggers inflammation and may result in autoantibody production. The International literature describes only three cases of mesothelioma presenting with SLE seropositivity (Rakhra, 2019;Javierre, 2011). Thus, the patient was considered as having MEM with paraneoplastic nephrotic syndrome and underwent renal biopsy.…”