Gonococcal pericarditis with tamponade in a patient with systemic lupus erythematosus

Abstract

Pericarditis is one of the most frequent manifestations of systemic lupus erythematosus; however, purulent pericarditis and tamponade are rare. We describe a patient with systemic lupus erythematosus and culture-proven gonococcal arthritis who developed purulent pericarditis with intracellular gram-negative diplococci. Evidence of tamponade was seen on echocardiography. There has not been a reported case of Nekseriu gonorrhoem in pericardial fluid or tissue since the introduction of antibiotics.Pericarditis in patients with systemic lupus erythematosus (SLE) is a frequent finding at the time of clinical presentation or upon autopsy; however, both purulent pericarditis and tamponade are rare (1-3). We recently saw a patient with SLE and gonococcal arthritis whose presentation mimicked a lupus flare and whose course was complicated by purulent pericarditis with echocardiographic evidence of tamponade. Her case is reported herein.Case report. The patient, a 35-year-old woman with SLE, developed fever, migratory polyarthralgias, and left-sided pleuritic chest pain in July 1988. On the first day of the illness, she had an acute onset of pain, swelling, and erythema of the small joints of both hands and the left wrist, accompanied by a small, painless, erythematous vesicle on the left thumb. Two days later, she developed fever, pleuritic chest pain, and mild dyspnea. By the fourth day, she was ill enough to seek medical attention. Although her white blood cell (WBC) count was elevated on initial presentation (20 x 109/liter), a lupus flare was presumed, and she was started on a regimen of prednisone, 60 mg/ day. One week later, the chest pain had subsided and the polyarthralgias had cleared; however, the left wrist became swollen and tender. Prednisone was increased to 80 mg/day. During the next week, the wrist pain worsened, and was associated with fever as high as 40°C and recurrent rigors. The patient was referred to the Washington Hospital Center and was admitted.The medical history revealed that 8 years prior to this time, the patient had presented with malar rash, alopecia, arthralgias, serositis, and anemia. Fluorescent antinuclear antibody was positive. The diagnosis of SLE was made, and steroid therapy was initiated. She responded well, and steroids were tapered over the next year and a half. She was well during this time, occasionally using ibuprofen for arthralgias. The remainder of the medical history was remarkable for a partial hysterectomy, which had been performed within the year prior to admission, and a remote history of pelvic inflammatory disease. Four weeks prior to admission, she noted a vaginal discharge.On admission, she was acutely ill with a temperature of 40.0"C and a pulse rate of 12Olminute. The left wrist was exquisitely tender, warm, and swollen. There was tenderness along flexor tendon surfaces proximal to the left wrist and erythema on the anterolateral left ankle. A shallow ulcer (0.5 cm) was ob-

The spectrum of pericardial tamponade in systemic lupus erythematosus: Report of ten patients

“…Although lupus-related serositis and uremia are the most common causes of tamponade in SLE, septic pericarditis must also be considered in the differential diagnosis, with 5 cases reported thus far (32)(33)(34)(35)(36). In 3 of these cases, the patient had longstanding SLE, and had a recent flare of disease that included a pericarditis which had been treated with high-dose steroids.…”

Pericardial Tamponade Masquerading as Septic Shock

“…Septic arthritis leading to pericardial infection is equally uncommon. An association between septic arthritis and purulent pericarditis has been observed with Hemophilius Influenza ,6 Neisseria meningitides ,7 and Neisseria gonorrhoeae 8. The simultaneous occurrence of Proteus arthritis and pericarditis in this patient is unique and has not been previously reported.…”

Gonococcemia mimicking a lupus flare in a young woman

“…A case of gonococcal endocarditis and a case of pericarditis with tamponade were described in the 1990s, with a good outcome after antibiotics. 6,7 In conclusion, this case shows the difficulty in distinguishing lupus flares from infectious diseases, and reminds us of the importance that should be attached to the risk of neisserial infections in patients with systemic lupus erythematosus.…”