A 39-year-old male presented with a chief complaint of chest pain that worsened with deep breathing for one day. He was found to be tachycardic, with distant heart sounds and a skin nodule over his right upper extremity. ECG revealed diffuse ST elevations and PR segment depressions with TTE showing a small pericardial effusion. Troponin I was 8.98 ng/mL and NT-proBNP was 981 pg/mL.
One day after admission, he developed respiratory distress, and repeat TTE showed a large pericardial effusion with collapse of the RV free wall during diastole with variation of mitral and tricuspid valve inflows consistent with tamponade. Pulsus paradoxus was 24 mmHg and he was taken for pericardiocentesis. Skin nodule biopsy revealed nodular and interstitial granulomatous dermatitis. Anti-nuclear antibody and double stranded DNA antibody were positive with pericardial fluid cytology showing acute inflammation with lupus erythematosus cells. Based upon this constellation of findings, he was diagnosed with systemic lupus erythematosus (SLE) myopericarditis, and started on colchicine and immunosuppression, with resolution of symptoms.
One week into hospitalization, the chest pain recurred but was sharp and substernal, with a rising troponin from 1.23 ng/mL to 8.23 ng/mL. TTE showed depressed LVEF of 45% and RCA territory hypokinesis without effusion. CTA PE showed no evidence of thromboembolism and CT coronary demonstrated mural thickening of the mid LAD and aneurysmal dilation of the left main to the LAD and left circumflex bifurcation concerning for vasculitis. The mid RCA was occluded, and patient was taken to the cardiac catherization laboratory revealing thrombotic occlusion of the proximal-to-mid RCA. Despite serial balloon dilation, thrombotic occlusion persisted, Aspiration thrombectomy evacuated organized thrombus prior to deployment of two overlapping drug-eluting stents in the proximal-to-mid RCA, restoring flow. TTE prior to discharge showed normal LVEF and no effusion.
This case illustrates various cardiac manifestations of SLE and the unusual dynamic nature of this patient’s multiple presentations of chest pain. Avoiding “diagnostic anchoring” is important to diagnosing and treating conditions such as SLE, that can affect the heart in multiple ways.
The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries
