(259) Psychiatric Puzzle to Cardiac Crisis: Lupus Myocarditis in a Woman With Systemic Lupus Erythematosus

Introduction: Systemic lupus erythematosus (SLE) can have grave complications resulting in critical illness. Among those are pleuro-pericarditis and lupus myocarditis (LM). LM (occurring in 5-10% of SLE patients) is characterized by inflammation of the myocardium, with likely escalation to heart failure (1). Diagnosis can be challenging. Cardiac MRI is the non-invasive modality of choice (1). Management involves addressing SLE with immunosuppressants; early recognition and aggressive intervention are critical for improving outcomes. We present a complex case of SLE related pleuro-pericarditis, myocarditis, and probable cerebritis resulting in critical illness.

Description: A 30-year-old female with history of small bowel obstruction treated surgically and hospitalization for psychosis the following month presented with shortness of breath a few weeks later. Physical exam revealed gross volume overload with bilateral lower extremity edema, anasarca, orthopnea, and cardiomegaly. CT scan demonstrated ground-glass opacities, dense consolidation, bilateral pleural effusions, and pericardial effusion. Echocardiography showed left ventricular ejection fraction of 20%, severe global hypokinesis, mitral regurgitation, tricuspid regurgitation, and a small pericardial effusion. IV nitroprusside, furosemide, and non-invasive positive pressure ventilation were used for afterload reduction. Autoimmune workup with elevated ANA (1:5120), CRP (47.6), anti-dsDNA (1:1280) and low C3/C4 confirmed underlying SLE. EULAR/ACR score was 19. There was concern that recent psychosis was attributed to lupus cerebritis. She declined a lumbar puncture. High dose glucocorticoids were initiated and the patient was transferred to a tertiary referral center.

Discussion: This case underscores the importance of considering SLE in patients with overlapping cardiac and psychiatric symptoms. The complexity of managing concurrent infections, significant cardiac dysfunction, and potential neurological involvement necessitates a coordinated, multidisciplinary approach. The patient's refusal of diagnostic procedures and need for advanced imaging highlight the challenges in managing SLE with multi-organ involvement. Early recognition and comprehensive treatment strategies are essential for improving outcomes in such complex presentations.