SESSION TITLE: Critical Care Student/Resident Case Report Posters III
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: We present a challenging and rare case of new onset multi-organ Systemic Lupus Erythematosus (SLE) with abrupt presentation, which was managed in our ICU.
CASE PRESENTATION: A 21-year-old African American female presented to the emergency department for strange behavior. Another facility treated Patient for psychiatric complaints and prescribed an antipsychotic. She was tachycardic and had bilateral lower extremity ulcers. Labs showed hemoglobin 9.3, hematocrit 30.1, ALT 178, AST 346, and alkaline phosphatase 131. EKG showed sinus tachycardia and diffuse T-wave inversions. Chest X-ray showed cardiomegaly, and lumbar puncture was normal. On the medical floor, Patient’s condition deteriorated. She developed hypoxic respiratory failure and was intubated in the ICU. Chest CT showed bilateral pleural and pericardial effusions with ground glass opacities. Echocardiogram showed ejection fraction (EF) of 30% with anterior wall hypokinesis. Further workup revealed positive antinuclear antibody, double stranded DNA antibody, Smith antibody, and histone antibody levels confirming SLE. Rheumatologist started patient on parenteral steroids, broad-spectrum antibiotics, and cyclophosphamide. Patient was doing well, was extubated, and then re-intubated secondary to hypoxia and lactic acidosis. Repeat echocardiogram showed EF of 20%. Patient was started on IVIG (Flebogamma) for worsening myocarditis and also on mycophenolate mofetil for worsening renal function. Patient's condition clinically improved, and was discharged to short-term rehabilitation center.
DISCUSSION: Identifying and managing SLE is a challenge in the ICU. Up to 42% of individuals with an autoimmune disease (AD) are first diagnosed during their ICU stay, and the in-ICU mortality of patients with ADs reaches as high as 55%, with infection as a major cause. The high mortality rate indicates a need for greater awareness of unique presentations of SLE and other ADs. Our patient’s initial psychiatric presentation was misdiagnosed as a primary psychiatric illness rather than a manifestation of SLE. The respiratory system is the most commonly affected in acute SLE, followed by the renal, gastrointestinal, and nervous systems. Our patient had neurological, cardiac, pulmonary, skin, hematologic and renal manifestations. The mainstay of management is based on the systems affected. For SLE, ICUs should consider using rituximab, IVIG and therapeutic plasma exchange in addition to conventional treatment.
CONCLUSIONS: ADs should always be considered in critically ill patients, and prompt recognition and management may help improve patient outcome.
Reference #1: Autoimmune diseases in the intensive care unit. An update. Quintero OL, Rojas-Villarraga A, Mantilla RD, Anaya JM. Autoimmunity Reviews, Vol. 12, Is. 3, Jan. 2013
Reference #2: Rheumatologic diseases in the intensive care unit: epidemiology, clinical approach, management, and outcome Namieta M. Janssen, Dilip R. Karnad, Kalpalatha K. Guntupalli Crit Care Clin 18 (2002)
DISCLOSURE: The following authors have nothing to disclose: Christopher Caesar Williams, Sonia Carvajal, Vanita Gupta
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