Sudden Death in a 55-Year-Old Woman With Systemic Lupus Erythematosus

Abstract

A 55-year-old woman with systemic lupus erythematosus (SLE) and hypertension was admitted for evaluation of a 1-week history of dyspnea and pleuritic chest pain. SLE was diagnosed 3 years ago and manifested as rash, recurrent angioedema, and arthritis. Maintenance therapy with continuous prednisone (10 to 50 mg/d) and briefly with methotrexate for 1 year controlled disease manifestations.Two months before admission, she developed increasing fatigue and malaise. One week before admission, a mild, nonproductive cough and chills were noted. Over the next several days, she developed progressively increasing dyspnea on exertion and bilateral, sharp, anterior chest pain that worsened with inspiration, supine position, and movement.The remainder of the past medical history was notable only for a miscarriage. Family history was unremarkable. The patient was a retired bookkeeper. She had smoked one-half pack of cigarettes per day for 20 years and had 1 alcoholic drink per day. There was no history of illicit drug abuse. Medications at the time of admission were prednisone 10 mg and sustained release nifedipine 60 mg daily. The patient was allergic to penicillin.On physical examination, the patient was in moderate respiratory distress. Blood pressure was 160 to 180 over 90 to 105 mm Hg, heart rate was 120 bpm, respiratory rate was 30 to 40 breaths per minute, and temperature was 99.1°F. The neck veins were flat. Lung sounds were decreased halfway up on the left and one third of the way up on the right. No evidence of consolidation was noted. A loud, 3-component pericardial friction rub was heard. No murmur or gallop was appreciated. A pulsus paradoxus was not present. No active synovitis or joint findings were noted. Pertinent laboratory findings on admission are noted in the Table. The ECG on admission showed sinus tachycardia at 120 bpm. Hospital CourseThe patient was placed on oxygen with a 4-L nasal cannula with an oxygen saturation of 96%. A thoracentesis revealed 672 white blood cells, which were 95% neutrophils, 162 red blood cells, lactate dehydrogenase 805, total protein 5.3, pH 7.39, and Gram stain negative for organisms. She was diagnosed with serositis involving the pericardium and the pleura and placed on intravenous Solu-Medrol every 6 hours. Empiric erythromycin 500 mg IV every 6 hours was initiated.On the second hospital day, a transthoracic echocardiogram revealed a moderate pericardial effusion predominantly surrounding the right atrium without evidence of hemodynamic compromise. Left ventricular hypertrophy, normal chambers and function, and no significant valvular abnormalities were noted. The right ventricular systolic pressure was 40 mm Hg. A repeat thoracentesis was obtained for cell counts and showed 15 250 white blood cells and 5250 red blood cells with 97% neutrophils. The patient's dyspnea and pleuritic chest pain were unchanged. The erythromycin was discontinued. Laboratory evaluation was notable for a positive anticardiolipin antibody. Blood cultures and pleural fluid cytology were negative.On...

Sudden death in infective endocarditis

“…The coronary arteries might be affected by vasculitis, thrombi, and atherosclerosis. The most common cardiac manifestation in lupus patients is pericarditis 2. There have been signs of inflammation in 75% of the cases at autopsy, either active or quiescent.…”

Lupus carditis

“…Two main mechanisms are involved in the pathogenesis of coronary disease in patients with lupus: atherosclerosis, which is the more common pathological process, usually accelerated by the continued use of steroids, and coronary vasculitis, which is rare 8 . Similarly to what occurs in the general population, in this group of patients hyper-tension, smoking, cholesterol levels above 200ml/dL and obesity have equally been considered important coronary risk factors 10,16,21,23 . In rare cases, acute coronary obstruction may be caused by embolism resulting from Libman -Sacks endocarditis, an intracoronary in situ thrombosis or a vasospasm 10,12 .…”

“…The ECG evaluation shows peaked T waves and elevation of the ST segment which is not different from that seen in other causes of pericarditis 8,10.12 . The inflammation may reach the sinoatrial node or the atrioventricular node and provoke arrhythmias 23 .…”

“…Thus ventricular dysfunction caused by lupic myocarditis usually is not of a great magnitude, and therefore the so-called lupic cardiomyopathy is of high intensity rarely with symptoms and sometimes even without symptoms 10,23 . Cardiac failure may occur occasionally, mostly in association with severe dilated cardiomyopathy, this resulting from isolated myocarditis, or of several repeated episodes of myocarditis 10 .…”

“…Libman -Sacks endocarditis is primarily an anatomopathological not a clinical finding 22 . The lesions in this type of involvement are usually silent, and the occasional clinical problems associated with them are related more to embolic phenomenon or overlaying valvular dysfunction or heart failure 9,23 . The real prevalence of this type of involvement is hard to determine during clinical examinations alone, considering the fact that most of the murmurs heard on auscultation in lupus, which usually result from fever, anemia, tachycardia and cardiomegaly, are not associated with organic valvular disease 9,16,22,25 .…”