ACHY BREAKY HEART

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute pericarditis accounts for about 5% of presentations of acute chest pain. Of those cases of pericarditis an etiology is found in about 22% of cases. Etiologies commonly include neoplasms, tuberculosis, infections, collagen diseases and thyroid disorders. CASE PRESENTATION: Our patient is a 16 year old healthy female that presented to the hospital with six days of fever, sore throat, cough, pleuritic chest pain and progressive dyspnea. She was sent to the emergency department (ED) by her pediatrician due hypotension. Upon arrival her blood pressure (BP) while supine was 70/40 and 50/30 with standing, with a heart rate (HR) of 121 bpm. In the ED she received 3 liters of normal saline. On admission BP was 107/63, HR 90, respiratory rate 33 and oxygen saturation was 80% on room air. The patient appeared drowsy. Her hands were cold and her lower extremities were warm; capillary refill was 4 seconds. Cardiovascular exam was normal with no pericardial friction rub. Lung exam was significant for diffuse inspiratory and expiratory crackles and decreased breath sounds at the left lung base. Initial laboratory work was significant for hemoglobin 10.5 g/dl, Sodium 128 mEq/L, creatinine 1.3 mg/dl, AST 129 U/L, ALT 72 U/L and Albumin 2.7 gm/dl. Troponin peaked at 0.682 ng/ml. BNP 141 pg/ml. Electrocardiogram showed nonspecific T wave abnormalities. Respiratory viral panel and rapid strep were negative. Chest radiograph showed patchy left lower lobe airspace disease that progressed bilaterally within 24 hours. Initial echo showed normal biventricular function with trivial pericardial effusion. She was diagnosed with acute perimyocarditis and treated with Ketorolac and IV Furosemide. Over her hospital course her respiratory distress worsened and she developed a moderate to large pericardial effusion 2 days after her initial echo. Work up included positive ANA (1:5120, speckled pattern), positive lupus anticoagulant, smith antibody and RNP antibody. Our patient was diagnosed with lupus (SLE) pericarditis and she was treated with high dose Methylprednisolone and Hydroxychloroquine which improved her pericardial effusion. DISCUSSION: This is a case of a female diagnosed with SLE perimyocarditis with pericardial effusion. This patient did not initially meet criteria for lupus, but by the end of her hospital course she met 4/11 criteria. Cardiac disease is rarely a presenting manifestation of SLE and only 1% of cases of SLE, in children and adults, present with pericarditis. While it is rare to present with cardiac symptoms, most patient with SLE develop cardiovascular manifestations at some point. Asymptomatic pericarditis is found in >50% of patients with SLE. Myocarditis, endocarditis and CAD are rare manifestations. CONCLUSIONS: This case highlights the importance of having a high index of suspicion for lupus in a patient that is not responding to initial treatment for viral myocarditis. Reference #1: Ansari, A., Larson, P. H., & Bates, H. D. (1985). Cardiovascular manifestations of systemic lupus erythematosus: Current perspective. Progress in Cardiovascular Diseases, 27(6), 421–434. doi: 10.1016/0033-0620(85)90003-9 Reference #2: Zayas, R., Anguita, M., Torres, F., Gime´nez, D., Bergillos, F., Ruiz, M., … Valle´s, F. (1995). Incidence of specific etiology and role of methods for specific etiologic diagnosis of primary acute pericarditis. The American Journal of Cardiology, 75(5), 378–382. doi: 10.1016/s0002-9149(99)80558-x Reference #3: Durrance, R. J., Movahedian, M., Haile, W., Teller, K., & Pinsker, R. (2019). Systemic Lupus Erythematosus Presenting as Myopericarditis with Acute Heart Failure: A Case Report and Literature Review. Case Reports in Rheumatology, 2019, 1–7. doi: 10.1155/2019/6173276 DISCLOSURES: No relevant relationships by Alejandra Grana, source=Web Response