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Myopericarditis in a Korean Young Male With Systemic Lupus Erythematosus

Park KT, Hong KS, Han SJ, Yoon DH, Choi H, Lee MY, Ryu MS, Lee CW - Korean Circ J (2011)

Bottom Line: Myocardial involvement with clinical symptoms is a rare manifestation of systemic lupus erythematosus (SLE), despite the relatively high prevalence of myocarditis at autopsies of SLE patients.In this review, we report the case of a 19-year-old male SLE patient who initially presented with myopericarditis and was successfully treated with high dose of glucocorticoids.

Affiliation: Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea.

ABSTRACT

Myocardial involvement with clinical symptoms is a rare manifestation of systemic lupus erythematosus (SLE), despite the relatively high prevalence of myocarditis at autopsies of SLE patients. In this review, we report the case of a 19-year-old male SLE patient who initially presented with myopericarditis and was successfully treated with high dose of glucocorticoids.

Electrocardiogram and Echocardiogram. A: electorcardiogram (ECG) shows sinus tachycardia and diffuse T-wave inversion in which leads on the day of admission. B: parasternal short axis view shows pericardial effusion and decreased left ventricular ejection fraction. C: ECG shows normal sinus rhythm and left ventricular hypertrophy after glucocorticoid treatment. D: parasternal short axis views show improving left ventricular ejection fraction and decreasing pericardial effusion after glucocorticoid treatment.
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Figure 2: Electrocardiogram and Echocardiogram. A: electorcardiogram (ECG) shows sinus tachycardia and diffuse T-wave inversion in which leads on the day of admission. B: parasternal short axis view shows pericardial effusion and decreased left ventricular ejection fraction. C: ECG shows normal sinus rhythm and left ventricular hypertrophy after glucocorticoid treatment. D: parasternal short axis views show improving left ventricular ejection fraction and decreasing pericardial effusion after glucocorticoid treatment.

Mentions: He had hypoxemia due to ventilation-perfusion mismatch. The levels of cardiac markers were elevated; troponin-I 0.87 ng/mL (normal, 0-0.05 ng/mL) and myoglobin 371 ng/dL (normal, 16.3-96.5 ng/dL). Sputum smear and polymerase chain reaction tests were negative for acid-fast bacillus. An electrocardiogram (ECG) revealed sinus tachycardia and diffuse T-wave inversion in which leads (Fig. 2A). Echocardiography demonstrated severe left ventricular systolic dysfunction {left ventricular ejection fraction (LVEF) was 18%} with severe global hypokinesia and preserved wall thickness (Fig. 2B). A large amount of pericardial effusion was observed 13 mm anterior to the right ventricle, 18 mm around the right atrium and 2 mm posterior to the LV. There were no signs of cardiac tamponade on both echocardiography and clinical findings. At first, we suspected viral myopericarditis, and started conservative treatment for congestive heart failure and pericarditis. But, there was no improvement in LVEF as well as in the clinical findings. Viral markers for cytomegalovirus, Coxsackie virus B type 2, Herpes simplex virus, and Epstein-Barr virus were all negative. During conservative treatment, he complained of new-onset ankle joint pain and tender erythematous swellings in both the ankles. The immunofluorescence tests were positive for anti-nuclear antibody (1 : 640 titre), anti-dsDNA antibodies (683.4 IU/mL), and anti-extractable nuclear antigen antibodies (anti-Sm, anti-RNP, anti-Ro, and anti-La), and the complement level was low (Table 1). We concluded that the patient had SLE according to the American Rheumatism Association/American College of Rheumatology classification criteria for SLE. On the 13th day of admission, we started treatment with high-dose glucocorticoids (methylprednisolone 1,000 mg intravenously daily for three days followed by 1 mg/kg per day in divided doses). On follow-up examination, ECG showed normalization of T-wave inversion (Fig. 2C) and echocardiography obtained just before discharge showed improved systolic function (Fig. 2D). Chest X-ray also showed improving consolidation in both the lung fields and cardiomegaly (Fig. 1B). Complement 3 was normalized and anti-dsDNA antibodies decreased from 683.4 IU/mL to 383.8 IU/mL (WHO u/mL, normal 0-93). He was discharged on the 33rd day of admission with oral prednisolone, and he visited the outpatient department 1 month later. In this 1 month, he had no symptoms. Echocardiography revealed normal LVEF, without significant valvular disease and pericardial effusion compared to the last examination (Table 2). Subsequently, the steroid medication was tapered and it was planned to maintain him on SLE-specific treatment in the Rheumatologic department.

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Myopericarditis in a Korean Young Male With Systemic Lupus Erythematosus

Park KT, Hong KS, Han SJ, Yoon DH, Choi H, Lee MY, Ryu MS, Lee CW - Korean Circ J (2011)

Electrocardiogram and Echocardiogram. A: electorcardiogram (ECG) shows sinus tachycardia and diffuse T-wave inversion in which leads on the day of admission. B: parasternal short axis view shows pericardial effusion and decreased left ventricular ejection fraction. C: ECG shows normal sinus rhythm and left ventricular hypertrophy after glucocorticoid treatment. D: parasternal short axis views show improving left ventricular ejection fraction and decreasing pericardial effusion after glucocorticoid treatment.
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Figure 2: Electrocardiogram and Echocardiogram. A: electorcardiogram (ECG) shows sinus tachycardia and diffuse T-wave inversion in which leads on the day of admission. B: parasternal short axis view shows pericardial effusion and decreased left ventricular ejection fraction. C: ECG shows normal sinus rhythm and left ventricular hypertrophy after glucocorticoid treatment. D: parasternal short axis views show improving left ventricular ejection fraction and decreasing pericardial effusion after glucocorticoid treatment.
Mentions: He had hypoxemia due to ventilation-perfusion mismatch. The levels of cardiac markers were elevated; troponin-I 0.87 ng/mL (normal, 0-0.05 ng/mL) and myoglobin 371 ng/dL (normal, 16.3-96.5 ng/dL). Sputum smear and polymerase chain reaction tests were negative for acid-fast bacillus. An electrocardiogram (ECG) revealed sinus tachycardia and diffuse T-wave inversion in which leads (Fig. 2A). Echocardiography demonstrated severe left ventricular systolic dysfunction {left ventricular ejection fraction (LVEF) was 18%} with severe global hypokinesia and preserved wall thickness (Fig. 2B). A large amount of pericardial effusion was observed 13 mm anterior to the right ventricle, 18 mm around the right atrium and 2 mm posterior to the LV. There were no signs of cardiac tamponade on both echocardiography and clinical findings. At first, we suspected viral myopericarditis, and started conservative treatment for congestive heart failure and pericarditis. But, there was no improvement in LVEF as well as in the clinical findings. Viral markers for cytomegalovirus, Coxsackie virus B type 2, Herpes simplex virus, and Epstein-Barr virus were all negative. During conservative treatment, he complained of new-onset ankle joint pain and tender erythematous swellings in both the ankles. The immunofluorescence tests were positive for anti-nuclear antibody (1 : 640 titre), anti-dsDNA antibodies (683.4 IU/mL), and anti-extractable nuclear antigen antibodies (anti-Sm, anti-RNP, anti-Ro, and anti-La), and the complement level was low (Table 1). We concluded that the patient had SLE according to the American Rheumatism Association/American College of Rheumatology classification criteria for SLE. On the 13th day of admission, we started treatment with high-dose glucocorticoids (methylprednisolone 1,000 mg intravenously daily for three days followed by 1 mg/kg per day in divided doses). On follow-up examination, ECG showed normalization of T-wave inversion (Fig. 2C) and echocardiography obtained just before discharge showed improved systolic function (Fig. 2D). Chest X-ray also showed improving consolidation in both the lung fields and cardiomegaly (Fig. 1B). Complement 3 was normalized and anti-dsDNA antibodies decreased from 683.4 IU/mL to 383.8 IU/mL (WHO u/mL, normal 0-93). He was discharged on the 33rd day of admission with oral prednisolone, and he visited the outpatient department 1 month later. In this 1 month, he had no symptoms. Echocardiography revealed normal LVEF, without significant valvular disease and pericardial effusion compared to the last examination (Table 2). Subsequently, the steroid medication was tapered and it was planned to maintain him on SLE-specific treatment in the Rheumatologic department.

Bottom Line: Myocardial involvement with clinical symptoms is a rare manifestation of systemic lupus erythematosus (SLE), despite the relatively high prevalence of myocarditis at autopsies of SLE patients.In this review, we report the case of a 19-year-old male SLE patient who initially presented with myopericarditis and was successfully treated with high dose of glucocorticoids.

Affiliation: Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea.

ABSTRACT

Background: Myocardial involvement with clinical symptoms is a rare manifestation of systemic lupus erythematosus (SLE), despite the relatively high prevalence of myocarditis at autopsies of SLE patients. In this review, we report the case of a 19-year-old male SLE patient who initially presented with myopericarditis and was successfully treated with high dose of glucocorticoids.

View Similar Images In: Results  - Collection
View Article: Pubmed Central -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=3132697&rFormat=json&query=null&req=5