PLEURAL EFFUSION AS AN INITIAL PRESENTATION OF SYSTEMIC LUPUS ERYTHEMATOSUS

Document Type

Conference Proceeding

Publication Date

7-17-2025

Publication Title

J Gen Intern Med

Keywords

apixaban, double stranded DNA antibody, doxycycline, heparin, prednisone, sultamicillin, abdominal pain, adult, case report, clinical article, conference abstract, cytology, deep vein thrombosis, diagnosis, disease severity, drug therapy, dyspnea, erythrocyte sedimentation rate, fatigue, female, fever, follow up, gastrocnemius muscle, heart failure, human, hypertension, kidney failure, lung embolism, medical record review, neutrophil, oxygen saturation, pleura effusion, pleura fluid, pleura thickening, pleurisy, pneumonia, positron emission tomography, splenomegaly, systemic lupus erythematosus, tachycardia, therapy, thoracocentesis, walking

Abstract

CASE: Systemic lupus erythematosus (SLE) is an autoimmune disease that adversely affects multiple organs. Pleural effusion is a common feature of SLE; however, as an initial presentation in SLE, is rare. Here, we present a case of SLE that presented for the first time with shortness of breath and fever and was found to have pleural effusion on imaging. IMPACT/DISCUSSION: A 48-year-old female with a history of hypertension presented with low-grade fevers, fatigue, shortness of breath, and abdominal pain for three weeks. Workup was significant for elevated erythrocyte sedimentation rate at 73 mm/Hr, and a CT chest abdomen pelvis showed a trace left pleural effusion or mild pleural thickening, and spleen enlargement at 18 cm. She was discharged and referred to hematology/oncology, who suspected a rheumatologic cause and recommended a positron emission tomography scan. Worsening symptoms brought her back to the ED one week after discharge. She was found to have a small right pleural effusion and moderate right basilar consolidation. She was started on Ampicillin / Sulbactam and Doxycycline for suspected pneumonia and sent to our hospital. At our hospital, the patient arrived tachycardic at 112 beats per minute and tachypneic at 28 respirations per minute. Her stay was complicated by a fever, and low oxygen saturation at 83% when walking, prompting further imaging that showed worsening pleural effusion (Figure 1) and was negative for a pulmonary embolism. Thoracentesis was done, and fluid analysis revealed an exudative pattern. The fluid cytology was negative for malignant cells. She started reporting bilateral calf tightness during her stay, and imaging revealed right occluding acute deep vein thrombosis of the proximal to mid-calf gastrocnemius vein and left occluding acute deep vein thrombosis of one of the paired peroneal veins. The patient was started on Heparin which was later switched to Apixaban. Rheumatology was consulted, and they suspected SLE as the cause of her symptoms. They recommended further workup, which was remarkable for low C3 and C4 at 67 and 9 mg/ dl respectively. She was also found to have positive anti-double-stranded DNA antibodies with a titer > 1:320, and chart review showed a previous positive ANA with a titer of 1:640 from 6 months ago. She met the criteria for SLE and was discharged stable on a Prednisone taper, with a follow-up with rheumatology. CONCLUSION: Pleural effusions occur in up to 60% of SLE patients, making them the most common pulmonary manifestation, though they are rarely the initial presentation. These effusions can be primary (due to lupus pleuritis) or secondary to conditions like infection, heart failure, or renal failure. They are usually bilateral and small-to-moderate in size. Pleural fluid analysis is essential for diagnosis, often showing an exudative pattern with neutrophils predominating. Management depends on symptom severity, with small effusions typically resolving on their own.

Volume

40

First Page

S290

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