When SLE Holds the Key to the Heart's Malady

Background Lupus is known as the great masquerader for its myriad manifestations. Men comprise only 10% of adult lupus patients. Myopericarditis is seen infrequently with an incidence of 9% and more commonly in African Americans. Case A 32 year old Caucasian male came to the ED for worsening dyspnea. History was notable for hair loss, a facial rash, occasional pleuritic chest pain and weight loss. Hemoglobin: 9.5 mg/dl, creatinine: 1.1 mg/dl and pro-BNP: 43,448 pg/ml. UA revealed hematuria and proteinuria. ECG showed sinus tachycardia with non-specific T wave changes. CXR showed bilateral pleural effusions. Echo revealed an EF of 24% with a dilated and globally hypokinetic LV, mitral regurgitation and a small pericardial effusion. Decision Making His presentation of multi-system involvement tipped further investigation of systemic illnesses. ANA, DSDNA were positive with low C3 and C4. CMR was consistent with myopericarditis and endomyocardial biopsy confirmed this. He was treated with pulse dose steroids and rituximab before transitioning to mycophenolate. 1 month follow up echo showed improvement in LV function with EF of 47%. Conclusion A thorough history was key to identifying the atypical presentation of lupus in this young Caucasian male presenting with heart failure. This case highlights one of few scenarios where immunosuppressive therapy is used in Cardiology. Advancements in multimodal imaging mean such complex diagnoses will be detected more, emphasizing the need to familiarize ourselves with such treatments to best serve our patients.