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Title

CARDIAC TAMPONADE AS AN INITIAL MANIFESTATION OF SYSTEMIC LUPUS ERYTHEMATOSUS: A REPORT OF TWO CASES

Background

Pericardial involvement may precede the clinical signs of systemic lupus erythematosus (SLE). Pericardial effusion, the most common echocardiographic abnormality found in SLE, is reported in more than 50% of patients and generally asymptomatic. Major and/or hemodynamic strokes resulting in cardiac tamponade are rare in SLE, as is the development of late-onset constrictive pericarditis. We report 2 cases of patients with cardiac tamponade as an initial manifestation of SLE.

Case report

Case 1: a 26-year-old woman admitted with dyspnea on minimal exertion, tachycardia, anasarca and difficult-to-control hypertension. Exhibited arthralgia of the small and large joints in the previous month, followed by fever peaks, malar rash, mouth ulcers and significant alopecia. ANA: coarse speckled pattern > 1:640; homogeneous pattern 1:320; Anti DNA reagent > 1:40; protein/creatinine ratio: 0.9; moderate hypertensive retinopathy. TTE showing massive pericardial effusion with signs of cardiac tamponade and left ventricular hypertrophy. EF: 51%. No satisfactory response to methylprednisolone pulse therapy. Submitted to pericardiocentesis, draining 1200mL of pericardial fluid (figure 1). Progressed to hemodynamic stability and was discharged under 400mg hydroxychloroquine; 60mg/day prednisone, 1mg/kg azathioprine and antihypertensives. The patient was asymptomatic within 3 months, with a normal TTE. Case 2: a 16-year-old woman admitted with dyspnea, painful respiration, cough with hemoptysis, fever, tachycardia, significant anemia, ANA +, complement deficiency and proteinuria. Evidence of massive pericardial effusion, minor pleural effusion and alveolar hemorrhage (figure 2). Submitted to pericardiocentesis, draining 640mL of pericardial fluid, and methylprednisolone pulse therapy. Patient progressed to clinical improvement and hemodynamic stability. Pericardial effusion (figure 3) recurred, but without hemodynamic repercussions. Initiated monthly pulse therapy with cyclophosphamide and is currently asymptomatic.

Conclusion

Cardiac tamponade is a rare feature of lupus pericarditis. The patients described above responded well to pericardiocentesis and corticosteroids. These case reports demonstrate the importance of considering cardiac tamponade diagnosis in the initial presentation of patients with SLE and dyspnea or hemodynamic instability.

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