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Program

Internal Medicine

Training Level

Resident PGY 2

Institution

Henry Ford Hospital

Abstract

Case: The patient is a 32-year-old Asian male with PMH of ERSD secondary to minimal change disease (diagnosed at age 26) presented for acute onset shortness of breath, lower extremity edema, and abdominal distension. He underwent CTPE which showed large left pleural effusion, moderate pericardial effusion and as well as ascites. Transthoracic ECHO showed moderate to large pericardial effusion with evidence of tamponade physiology. The patient underwent emergent pericardiocentesis and placement of a pericardial drain. The pericardial fluid was bloody in appearance, fluid studies showed RBC 2047709, cytology negative malignancy and culture showing no growth. The patient also underwent left-sided thoracentesis with the removal of 1L bloody fluid with the placement of a left-sided pleural drain. Pleural fluid studies showed RBC 30803, cytology negative for malignancy and culture showing no growth. Furthermore, paracentesis was done with the removal of 800cc peritoneal fluid with bloody appearance. Fluid studies showed RBC 112577 and cytology negative for malignancy, negative cultures. Hemoglobin was around 8, platelets 102, CRP 18 and sed rate 53. ANA 1:640 speckled pattern, low C3 and C4, negative ANCA, RF, CCP, RNP, Smith ds DNA, SSA, SSB, C3 low and C4 normal (both initially low). He met 4/11 SLICC criteria for SLE including serositis, +ANA, anemia/thrombocytopenia and low complements, history of MCD. He was started on methylprednisolone resulting in the improvement of anemia/thrombocytopenia. Then transitioned to oral prednisone with a taper and was also started on plaquenil and imuran.

Impact/Discussion: To date, the association of SLE with MCD has been described only in isolated case reports. Initially, the etiology of the patient’s MCD was unclear. He had no history of lupus nephritis and no known causes for secondary FSGS, but failed to recover renal function and ultimately progressed to ESRD. His dramatic presentation suggests that MCD was a harbinger of SLE—the metaphorical canary in the coal mine. In the context of his past medical history and his particular demographic, initial clinical suspicion for SLE was low. This case contributes to the body of literature supporting early consideration of SLE as a potential etiology for MCD and acute pericarditis.

Conclusion: SLE is an autoimmune disorder with a wide spectrum of manifestations. Acute pericarditis is an important and potentially a life threatening complication of the disease. According to the most recent EULAR/ACR 2019 SLE criteria, acute pericarditis scores 6 points. A total of 10 points is required to diagnose SLE, thus recognizing SLE as a potential underlying cause in a newly diagnosed acute pericarditis or cardiac tamponade is crucial to initiate treatment and improve outcomes. A relevant association may exist between SLE and MCD.

Presentation Date

5-2020

The Canary in the Coal Mine

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