Case 4-1999

Abstract

A 38-year-old woman (gravida 3, para 2) was admitted to the hospital because of left-sided chest pain.The patient, who worked as a day-care provider, had been well until seven months earlier, when headaches and pain in the neck and shoulder began. One month later she was discovered to be pregnant. A test for antinuclear antibodies was positive, at a titer of 1:5120, with a nucleolar pattern of staining. Systemic lupus erythematosus was diagnosed, and prednisone was administered. Three months before admission, severe myalgias and progressive dysphagia developed, with a weight loss of about 7 kg.Four days before admission, the patient had sudden chest pain that became more severe and pleuritic and that was accompanied by dyspnea. She was admitted to another hospital. The results of laboratory tests at this time and throughout the course of the illness are presented in Tables 1, 2, and 3. A specimen of arterial blood, drawn while the patient was breathing room air, revealed that the partial pressure of oxygen was 76.3 mm Hg, the partial pressure of carbon dioxide was 32.1 mm Hg, and the pH was 7.44. A radionuclide ventilation-perfusion scan showed mismatch defects in the left lung. A pulmonary angiographic study revealed questionable "pruning" of the distal pulmonary arteries, without evidence of emboli. The pulmonary arterial pressure was 53/24 mm Hg, the right ventricular pressure was 49/9 mm Hg, and the right atrial pressure was 11 mm Hg. The creatine kinase concentration was 1200 U per liter, with an MB isoenzyme fraction of 3 to 4 percent. On the 4th hospital day (during the 24th week of gestation), the patient was transferred to this hospital, after she had received prednisone, aspirin, ranitidine, labetalol, a calcium supplement, and multivitamins.There was a questionable history of blood clots in both legs at the age of 16 years, without known recurrence.The temperature was 37.1°C, the pulse was 108, and the respirations were 26. The blood pressure was 110/70 mm Hg. Physical examination revealed only distant breath sounds, a few crackles at both bases, and a grade 2 systolic murmur. An electrocardiogram showed sinus tachycardia at a rate of 102, with left-axis deviation and minor, nonspecific STsegment and T-wave abnormalities. The results of an echocardiographic examination were normal; the estimated right ventricular systolic pressure was 45 mm Hg.Examination by fiberoptic upper gastrointestinal endoscopy disclosed a nonbleeding gastric ulcer, 6 mm in diameter, located at the gastroesophageal junction and related to a sliding hernia. Pulmonary-function studies were performed. The findings on an obstetrical ultrasonographic evaluation were normal. Microscopical examination of a biopsy specimen of the right quadriceps muscle showed slight myositis.