Case Report Underscores Varied Nature of SLE Presentation

In a case report published in Pediatric Emergency Care, researchers highlighted an individual with an initial presentation of supraventricular tachycardia subsequently found to have pancreatitis, myocarditis, and nephritis secondary to a new diagnosis of systemic lupus erythematous (SLE).

The case underscores the variety of ways in which lupus can present, given its ability to involve virtually any organ system. The chronic, autoimmune, multisystem disorder can sometimes be life threatening, while prognosis is often dependent on the organ system involved and severity of involvement, authors explained.

Clinical manifestations tend to involve a combination of skin, musculoskeletal, and mild hematologic complaints, and most individuals report the presence of fatigue at the time of diagnosis.

As the heart is one of the most frequently affected organs in patients with SLE, approximately one quarter of all individuals will develop symptomatic pericarditis at some point during the disease’s course.

In the current case, researchers assessed a previously healthy 17-year-old male who presented to an urgent care center with a 2-week history of nausea, abdominal pain, and weakness, among other symptoms.

“His initial electrocardiogram in the emergency department demonstrated sinus tachycardia with mild first-degree atrioventricular block. An initial set of laboratory tests was obtained, which revealed multiple abnormalities. The most notable of these included a creatinine of 3.66 mg/dL and a lipase of 2709 U/L,” researchers wrote. The patient was then admitted for acute renal failure and pancreatitis, they said.

Skin manifestations, including a recurring rash and photosensitivity were also recorded. The individual’s mother had died from congestive heart failure and lupus complications in her 30s.

Additional tests revealed the patient had:

• Anemia with hemoglobin of 11.2 gm/dL and leukopenia with a white blood cell count of 3.2103/uL
• +ANA, +dsDNA, +SSA, +RNP/Smith, and low complement level
• Nephrotic range proteinuria with 17,000 mg 24-hour urine protein
• New-onset systolic left-sided heart failure due to nonischemic cardiomyopathy with an ejection fraction of 25%

Following treatment with high-dose steroids, the individual received 3 days of pulse steroids and was transitioned to oral steroids. Throughout the patient’s stay, doctors identified multiple deep venous thromboses, for which he was started on apixaban.

Prior to discharge, the patient began mycophenolate mofetil and ulfamethoxazole-trimethoprim for pneumocystis pneumonia prophylaxis. He was sent home on mycophenolate mofetil, prednisone, and apixaban.

“Lupus myocarditis is rare, but when present often indicates severe systemic illness. The echocardiogram will often show global hypokinesis without evidence of coronary artery disease. This was the case with our patient,” authors wrote.

Overall, the patient exhibited some involvement of SLE in almost all organ systems. Additional factors also contributed to a poor prognosis, including renal disease, male, age, low socioeconomic status, African American race, and high disease activity.

“SLE is the great mimicker and can present in a variety of ways. Given its ability to involve virtually any organ system, it is important to consider it on the differential diagnoses, especially in patients with a strong family history,” researchers concluded.

Reference:

Rayburn D and Gerke S. Supraventricular tachycardia as the initial presentation of new-onset lupus: a case report. Pediatr Emerg Care. Published online September 1, 2021. doi:10.1097/PEC.0000000000002518