Cardiac Tamponade With Fibrin Strands Leading to the Diagnosis of Systemic Lupus Erythematosus
A 59-year-old male with an unremarkable past medical history presented with worsening dyspnea and a history of chest tightness for 2 weeks. He had arthritis of multiple hand and foot joints bilaterally. Muffled heart sounds and pulsus paradoxus of 15 mm Hg were noted on examination. Laboratory findings were remarkable for anemia, with a hemoglobin level of 8.9 g/dL (normal, 13.5 to 17 g/dL), proteinuria level of 0.9 g/d, positive antinuclear antibody level of 906 U/mL (normal, 0 to 99 U/mL), and positive anti-DNA (DS and SS) antibodies. A chest x-ray showed a large cardiac silhouette. A 2-dimensional transthoracic echocardiogram revealed a large circumferential pericardial effusion (Figure 1, asterisks), with remarkable intrapericardial adhesions (fibrin strands) that had a worm-like appearance and were partially attached and floating between the visceral and parietal pericardium (Figure 1 and Data Supplement Movie).
Pericardiocentesis was performed to drain 1700 mL of bloody fluid. Posteroanterior chest x-ray (Figure 2) showed the heart before (left) and after (right) pericardiocentesis. An ECG (Figure 3) before (upper) and after (lower) pericardiocentesis is shown.
The final diagnosis of systemic lupus erythematosus presenting with cardiac tamponade was made.
The online-only Data Supplement, which contains a movie, can be found at http://circ.ahajournals.org/cgi/content/full/116/11/e342/DC1.