¹Samah Allam, ¹Noha Yaseen, ³Suad Hannawi

¹EHS/ Al Qassimi hospital, ²EHS/ Kwuaiti Dubai hospital, ³MOHAP, Dubai

Introduction: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease of unknown cause that can affect virtually any organ of the body. Immunologic abnormalities, especially the production of a number of antinuclear antibodies (ANA), are a prominent feature of the disease.

Patients can present with variable clinical features ranging from mild joint and skin involvement to life-threatening kidney, hematologic, or central nervous system involvement. The clinical heterogeneity of SLE and the lack of pathognomonic features or tests pose a diagnostic challenge. To complicate matters, patients may present with only a few clinical features of SLE, which can resemble other autoimmune, infectious, or hematologic diseases.

More than 90% of cases of SLE occur in women, frequently starting at childbearing age. The onset of SLE is usually after puberty, typically in the 20s and 30s, with 20% of all cases diagnosed during the first 2 decades of life, with the prevalence of SLE is highest in women aged 14 to 64 years.

Method(s): We are presenting a geriatric woman of 75-year-old that was newly diagnosed with Systemic Lupus Erythematous with hematological, renal, and cardiac manifestations.

Result(s): Mrs. Z.G. is a 75-year-old, Palestinian female known case of mitral valve disease, atrial fibrillation (AF), and hypothyroidism. She was on trimetazidine 35 mg BID, atenolol 50 mg BID, furosemide 40 mg daily, oral anticoagulant apixaban 5mg BID, and levothyroxine 75 mg daily. Mrs. Z.G. presented to the emergency with chest pain, and shortness of breath, for 2 days, together with a cough with no history of fever.

In the emergency room, she was hypotensive (BP89/54), temp.36.5°C, HR 106 (ECG show AF controlled rate)

Blood investigations show pancytopenia; WBC 1.15 x10(3)/mcL (RR 4-11), absolute neutrophils 0.48 x10(3)/mcL(RR 2-7), HB9.2 gm/L ( RR 11.5-15.5),  platelets 78 x10(3)/mcL( RR 150-450). ESR 112 mmHg (RR 0-30), CRP 4.5mg/L (RR 0-3), Pro BNP 3902 pg/mL (RR 0-125)

Physical examination showed pale elderly women with evidence of malar rash or any skin lesions.

By auscultation, the patient had diminished air entry on the left side with a pan systolic murmur at the mitral region.

Chest X-ray shows Moderate left-sided pleural effusion with underlying lung compressive collapse, marked cardiomegaly

Further blood work showed positive ANA, dsDNA, anti-SSA, and anti-SSB, with low complements (C3, C4) and Urinary 24protiens of 1,256mg/day (RR10-149)

ECHO showed Moderately Impaired LV, systolic function EF 40%, Global hypokinesia

Dilated left atrium, Grade II diastolic dysfunction, Mitral valve is thickened with a nodule seen in anterior mitral valve leaflet( Figure1, Figure 2), there was also severe Mitral regurgitation, effective regurgitant orifice area 0.43 cm2 , regurgitant volume 52ml, vena contracta 0.8 cm. The regurgitant jet is eccentric, swirling posteriorly, maximum velocity of 4.2 m/s (Figure 3). Proximal iso velocity surface area diameter is 0.8 cm, mild to moderate tricuspid regurgitation

Severe pulmonary hypertension, estimated pulmonary pressure 64 mmHg, no intracardiac thrombus noted, Moderate effusion with fibrinous strands, size 1.6 cm inferiorly, and Pleural effusion noted.

Based on the clinical presentation, and laboratory findings, a diagnosis of SLE had been given.

Mrs. Z.G. was started on pulsed steroids for 3 days 1gm daily for 2 successive days, followed with oral prednisolone 1gm/kg then tapered gradually, together with hydroxyl chloroquine 200 mg BID and mycophenolate mofetil 500 mg BID that was escalated gradually to 2 gm daily. Mrs. Z.G. was shifted from oral apixaban to warfarin with a target International normalized ratio (INR) of 2-3

Mrs. Z.G. was reviewed after that in follow-up visits, show marked clinical improvement, a repeat of ECHO showed marked improvement in the mitral valve regurgitation from severe degree to mild to moderate mitral regurgitation (Figure 4).  Repeated ECHO showed also improvement in LV function.

Conclusion(s): SLE can present for the first time at an elderly age. The first presentation can be a cardiological manifestation with Libman- Sacks endocarditis, pancarditis affecting the tricuspid valve and LV function, pericarditis, and pleural effusion.