A 77-year-old male non-smoker with a history of restrictive syndrome due to pneumoconiosis and bilateral multisegmental pulmonary thromboembolism came to the emergency department of our hospital presenting a clinical picture of muscular discomfort and weakness.
The patient was questioned about progressive deterioration of the general condition one month after being discharged from hospital due to pneumonia of the right lower lobe with parapneumonic pleural effusion.
It was accompanied by profuse sweating and fatigue.
Physical examination revealed a blood pressure of 95/60 mmHg, axillary temperature of 39.5 oC, heart rate lat/min, auscultation 35, respiratory auscultation with no auscultation crackles at baseline.
Complementary examination performed at admission revealed a sedimentation rate of 105, hemoglobin 12.8 g/dl, MCV 81, leukocytes 6350/μl, 244,000 platelets/μl, normal urea activity 56 g albumin 5.
The ECG showed sinus rhythm at 98 beats/min, low voltage and nonspecific repolarization disorders.
A chest X-ray showed a small bilateral pleural effusion.
Chest CT showed bilateral, atypical pleural effusion with loculations, and moderate pericardial effusion.
For this reason, an echocardiographic study was performed, which was reported as absence of signs of tamponade, moderate dilation of the left atrium, a left ventricle with mild concentric hypertrophy, a LVEF of 60%, alteration of the left ventricle.
The valves were normal, with small calcium plaques in the mitral valve.
An exudate was obtained with 67% PMN, 33% mononuclear, glucose 90, proteins 4.3, pH 7.34, ADA 25, LDH 363.
No germs in gram, negative BAAR, negative Lowestein culture and negative cytology.
An X-ray showed changes in relation to highly evolved primary osteoarthritis, affecting both hands, especially the distal interphalangeal and metaphalangeal joints.
Given the clinical data and the presence of pericardial effusion, despite the absence of signs indicative of cardiac tamponade, it was decided to perform a parietal window, obtaining pericardium fluid with diagnostic left anterior pericardiotomy in 150 samples.
Pathological examination showed mild inflammation with no evidence of cells.
1.
Since the results obtained in the complementary examinations were inconclusive, it was decided to perform a battery of immune determinations including ANA, anti-ENA, anti-SSNPA, anti-DNA, anti-clSSR, anti-ANCA.
ANA (1/320 with a homogeneous pattern), anti-ENA and anti-SSA were considered positive.
C3 and C4 levels were 146 mg/dl and 28 mg/dl respectively. The findings led to the diagnosis of SLE.
Treatment was initiated with prednisone 10 mg/12 h, resulting in clinical improvement and remission of fever.
In subsequent controls, pericardial effusion disappeared completely.
