American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

Systemic Lupus Erythematosus in an Elderly Man

(A) ECG with diffuse ST elevations consistent with acute pericarditis. (B) CT scan demonstrating large circumferential pericardial effusion. (C) Transthoracic echocardiogram showing early diastolic collapse of right atrium. (D) Exaggerated mitral inflow velocity on pulse wave spectral doppler suggestive of ventricular interdependence. (E) Air-dried Wright-Giemsa stained slide showing lupus erythematosus cells. LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.

 

We present the case of an 84-year-old white man with a remote history of an axillary liposarcoma and basal cell carcinoma who presented to the emergency department after 4 days of knee pain, extreme fatigue, weakness, and malaise. Although he was without chest pain, his electrocardiogram showed diffuse ST elevations. There was no troponin elevation, and initial echocardiogram showed no pericardial effusion. His erythrocyte sedimentation rate was elevated at 69 mm/h and C-reactive protein was elevated at 211.6 mg/L. Acute pericarditis was diagnosed; however, because of severe neutropenia, he was discharged without colchicine or nonsteroidal anti-inflammatory drug therapy. Three days later, he returned with dyspnea, tachycardia and hypotension. Computed tomography angiography with a pulmonary artery protocol demonstrated a large circumferential pericardial effusion. Echocardiogram confirmed the effusion and noted early diastolic collapse of the right atrium. Pulse-wave spectral Doppler demonstrated significant respiratory variation of the mitral inflow velocity indicative of ventricular interdependence. The clinical diagnosis of pericardial tamponade was suspected and emergent pericardiocentesis yielded 760 mL of bloody fluid. Analysis of the fluid by light microscopy on an air-dried Wright-Giemsa–stained slide noted the presence of lupus erythematosus cells, which are mature polymorphonuclear leukocytes that have phagocytized the nuclei of other cells and are characteristic of systemic lupus erythematosus. Lupus erythematosus cells were named after their discovery in the bone marrow of 25 patients with systemic lupus erythematosus by Hargraves et al at the Mayo Clinic in 1948, and for a period of time their presence was the most specific test available for systemic lupus erythematosus. Subsequent antinuclear antibody, immunoglobulin-G, anti-cardiolipin and antihistone autoantibodies were consistent with a diagnosis of systemic lupus erythematosus. Pericardial fluid cytology showed no evidence of malignancy. Our patient was treated with steroids and hydroxychloroquine. He responded well and has been without recurrence of symptoms or pericardial effusion for more than 3 years. This case highlights the importance of light microscopy in the evaluation of an unexplained pericardial effusion, because the diagnosis of systemic lupus erythematosus may otherwise have been overlooked in an elderly man.

 

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-James C. Lee, MD, John K. Amory, MD, MPH, Creighton W. Don, MD, PhD

This article originally appeared in the March 2016 issue of The American Journal of Medicine.

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