A 19-year-old woman comes to the emergency department due to a 4–5-day history of chest discomfort that radiates to the nuchal fold and shoulders bilaterally. The patient took over-the-counter ibuprofen and had some pain relief. She reports associated fatigue and bilateral knee pain yesterday, which has since resolved. The patient has a history of systemic lupus erythematosus, for which she takes hydroxychloroquine. She does not smoke or take illicit drugs. The patient has no family history of cardiovascular diseases. Temperature is 38.3 C (100.9 F), and blood pressure is 110/70 mm Hg in the upper extremities bilaterally. Examination shows an erythematous rash over the cheeks and the nasal bridge. Pain is not reproducible with chest palpation. A superficial scratchy sound is heard between S1 and S2. Breath sounds are normal. ECG reveals sinus tachycardia at 103/min and diffuse T wave inversion. Laboratory results are as follows:
| Hemoglobin | 10.2 g/dL |
| Platelets | 90,000/mm3 |
| Creatinine | 1.3 mg/dL |
Serum troponin drawn on presentation is <0.01 ng/dL. Which of the following is the most likely explanation for this patient's symptoms?
Acute pericarditis | |
Etiology |
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Clinical features & diagnosis |
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Treatment |
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NSAID = nonsteroidal anti-inflammatory drug; SLE = systemic lupus erythematosus. | |
This patient most likely has acute pericarditis due to systemic lupus erythematosus (SLE). Pericarditis is the most common cardiac manifestation of SLE and usually occurs in the presence of other manifestations of active disease (eg, joint pain, fatigue, malar rash, anemia, thrombocytopenia).
Patients with pericarditis typically have pleuritic chest pain that can radiate posteriorly to the bilateral trapezius ridges (lower aspect of the bilateral scapulae). Fever may also be present. Auscultation at the left sternal border typically indicates a triphasic pericardial friction rub (heard in atrial systole, ventricular systole, and early ventricular diastole). Serum troponin levels may be slightly elevated but are often undetectable. Initial ECG typically shows subtle (diffuse) PR depression and diffuse ST elevation that eventually evolves to diffuse T wave inversion. Associated pericardial effusions are often observed on echocardiogram but are typically small in SLE-induced pericarditis.
First-line treatment of pericarditis due to SLE is with nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, ibuprofen); colchicine is rarely used. Corticosteroids (eg, prednisone) are appropriate initial treatment in patients with a contraindication to NSAIDs (eg, renal insufficiency), and, in addition, are often effective in patients who do not respond to NSAIDs.
(Choice B) Cervical arthritis can cause neck pain with radiation to the shoulders. However, a pericardial friction rub makes pericarditis the most likely cause of this patient's pain.
(Choice C) Costochondritis describes inflammation of the parasternal cartilage. Patients typically present with chest discomfort that is worse with movement and reproducible with chest palpation.
(Choice D) Patients with SLE often develop premature coronary artery disease in the fourth or fifth decade of life. However, myocardial ischemia would be quite rare in this young patient, even in the setting of underlying SLE.
(Choice E) Pulmonary embolism typically presents with sudden onset of dyspnea, pleuritic chest pain, and hypoxemia. Patients with SLE are at increased risk, but a pericardial friction rub is not typical.
(Choice F) Verrucous (Libman-Sacks) endocarditis is characterized by the deposition of sterile vegetation (eg, immune complexes, thrombus) on cardiac valves; it can occur in patients with advanced malignancy or SLE. Patients are usually asymptomatic but may have symptoms of systemic embolization (eg, focal weakness due to stroke).
Educational objective:
Pericarditis is the most common cardiac manifestation of systemic lupus erythematosus (SLE). Patients typically have pleuritic chest pain, a pericardial friction rub, and diffuse ECG changes accompanied by other manifestations of active SLE (eg, joint pain, cytopenia).