217: ACUTE SYSTOLIC HEART FAILURE AS THE INITIAL PRESENTATION OF SYSTEMIC LUPUS ERYTHEMATOSUS

Abstract

Learning Objectives: SLE is a chronic inflammatory illness, with a myriad of clinical presentations. Of these, cardiac involvement is frequent, with Pericarditis being the most common cardiac manifestation, and Myocarditis with subsequent cardiomyopathy being relatively uncommon. We present an interesting case of a previously healthy 19-year-old male presenting with new onset heart failure secondary to Lupus Cardiomyopathy. Methods: A 19-year-old male with no significant past medical history, presented to the ED with complaints of dyspnea on exertion, weakness, weight loss of 40lbs over 1 month, pedal edema, orthopnea, chills, non-productive cough, high grade fevers for 1 week and a non pruritic rash on bilateral cheeks. Denied recent viral illness, sick contacts or travel outside the US. He was tachycardic to 133, normotensive, hypoxemic requiring 2L oxygen by nasal cannula. Physical examination showed pedal edema, rales on lung exam. Lab evaluation revealed pancytopenia with WBC:2200/ uL, hemoglobin:9g/dL, platelet:93,000/uL, peripheral blood smear:normochromic anemia with no schistocytes, Lactic acid:2.7 mmol/L, peaked at 5.5 mmol/L. Troponin 0.15 ng/mL, peaked at 0.21. ECG showed t wave inversions in infero-lateral leads. Transthoracic Echocardiogram performed for t-wave changes, showed an LV EF: 15–20%, mild to moderate Mitral regurgitation and a small pericardial effusion. MICU admission was requested for persistent tachycardia, worsening lactic acidosis and acute systolic heart failure with concern for impending circulatory collapse. IV fluids and broad spectrum antibiotics were given. Further work up revealed positive ANA screen, ANA titer 1:640, Anti DS DNA positive: 226 IU/mL, low C3 and C4 levels, negative anti-phospholipid antibodies. Cardiology and Rheumatology services were consulted. Diagnosis of SLE was made based on 4/11 ACR criteria positive for SLE, new systolic heart failure was deemed secondary to lupus cardiomyopathy. Other common causes of myocarditis in the young were ruled out. Treatment was initiated with Plaquenil and high dose Methylprednisolone. Repeat echocardiogram performed 3 days later showed an improvement in LV EF to 30% and decrease in size of the pericardial effusion with improvement in pancytopenia. Results: Myocarditis and systolic dysfunction secondary to SLE are relatively rare causes of new onset heart failure in the young. Prompt recognition and initiation of treatment with high dose glucocorticoids, immunosuppressive agents or IVIG can be lifesaving. CCMCritical Care MedicineCrit Care Med0090-3493Lippincott Williams & WilkinsHagerstown, MDCCM