Sub-acute Cardiac Tamponade as an Early Clinical Presentation of Childhood Systemic Lupus Erythematosus: A Case Report

Abstract

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting multiple systems by the process of inflammation and formation of auto-antibodies. When it presents in childhood, it is referred to as childhood systemic lupus erythematosus (cSLE). Cardiac tamponade is a rare but potentially lethal complication of cSLE, even rarer as an initial presentation. Sub-acute cardiac tamponade (medical tamponade) is a non-emergent type of cardiac tamponade which develops slowly over time and does not necessarily present with acute distress.We present the case of an 11-year-old girl who presented to the emergency department with complaints of intermittent fever, periorbital puffiness, abdominal distension, and swelling on the hands and feet. She was not in any acute distress but was vitally unstable. Cardiovascular examination revealed muffled heart sounds. Chest examination further revealed decreased breathing sounds on the left side with dull notes on percussion. Abdominal examination revealed positive shifting dullness with a distended abdomen.Blood investigations were ordered which revealed anemia and thrombocytopenia. Chest X-ray showed an enlarged cardiac silhouette. Urine detailed report showed proteinuria and hematuria. Further investigations revealed the autoimmune root of the disease. Echocardiography was ordered which showed a large collection of fluid around the posterior aspect of heart with the concomitant collapse of atrial chambers suggestive of cardiac tamponade. A diagnosis of sub-acute cardiac tamponade secondary to childhood SLE was made. The patient was started on pulse therapy of methylprednisolone followed by a low-dose regime of mycophenolate mofetil. The patient was also provided with positive pressure ventilation, hemodialysis, and invasive cardiovascular monitoring along with the instillation of intravenous fluid supplements. To our knowledge, cases of sub-acute cardiac tamponade as the only and early clinical manifestation in childhood SLE are very rare.

Juvenile lupus, cytomegalovirus infection and cardiac tamponade: case report

“…Most studies describing this manifestation in pediatric patients consist of case reports. 24 Maharaj et al 23 described 13 cases of SLE in children who presented with cardiac tamponade as their first manifestation. The authors described a 92% female patient population, and pleuritis was present in 100% of the cases.…”

“…Some authors have described cases of SLE and cardiac tamponade in which all patients continued treatment with immediate pericardiocentesis guided by echocardiography, and clinical management continued with the use of high doses of corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and antimalarials. 23 , 24 When associated, CMV and cardiac tamponade can confuse the diagnosis and mislead the treatment. Antivirals may have pharmacologic interactions with the long-term management of cardiac complications, in addition to having its use delayed by the urgency of the clinical condition and being iatrogenically forgotten.…”

Cardiac tamponade in a male as an initial presentation of SLE. An interesting case report

“…Pericarditis, which has been associated with poor mortality, is the most frequent cardiac symptom of SLE. Approximately 25% of all SLE patients eventually have symptomatic pericarditis, most often in association with concurrent pleuritis [11]. In SLE, pericardial effusion is often mild and hemodynamically unimportant.…”

Dilated cardiomyopathy: An unusual and severe condition in juvenile systemic lupus erythematosus

“…While pericardial and endocardial damages are the most common, dilated cardiomyopathy (DCM) remains an unusual potentially severe event. 2 In the following article, we report a case of JSLE with DCM.…”