HYDRALAZINE-INDUCED PLEURITIS MASQUERADING AS HEART FAILURE
2023; Elsevier BV; Volume: 164; Issue: 4 Linguagem: Inglês
10.1016/j.chest.2023.07.2392
ISSN1931-3543
AutoresM. Deeb, RAVEENA MIDHA, RACHEL MOODY, FRANK M SCHEMBRI, MILANA SHTURMAN, KAMRAN MANZOOR,
Tópico(s)Pericarditis and Cardiac Tamponade
ResumoSESSION TITLE: Disorders of Pleura Case Report Posters 4 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Several medications have been associated with Drug-induced lupus (DIL), with the highest risk with procainamide (1) and hydralazine (2). We report a case of hydralazine-induced lupus in a patient admitted with a presentation typical for congestive heart failure (CHF), in which the diagnosis of DIL could have easily been missed. CASE PRESENTATION: A 66-year-old woman with a history of HFrEF (EF 35%), CAD, asthma, sleep apnea, and CKD, presented with a two-day history of dyspnea, decreased urine output, orthopnea and lower extremity edema. She was hypoxemic to the 80s on room air, but otherwise hemodynamically stable. Examination was notable for JVD to the mandible, a +2/6 systolic flow murmur, a possible friction rub, diminished breath sounds, dullness at the bases, and 2+ pitting edema to the upper shins. Laboratory work up revealed an AKI with a creatinine of 3.21 mg/dl and an elevated proBNP to 3195 pg/ml. Chest x-ray showed large bilateral pleural effusions (Fig. 1). Echocardiogram showed an LVEF of 35%, grade II diastolic dysfunction, moderate RV dilation, severe bi-atrial dilation, IVC dilation, pulmonary hypertension and a moderate circumferential pericardial effusion not significantly changed from prior. She was placed on BIPAP and diuresed. Her pleural effusions were initially attributed to CHF and given her hypoxia, a therapeutic right sided thoracentesis was done, which yielded 870 ml of serosanguinous fluid. Lights criteria surprisingly was consistent with an exudate effusion. An additional thoracentesis on the left side was also exudative in nature. Further workup revealed a serum CRP of 243, a serum ANA 1:2560, pleural fluid ANA of 1:320, and a strongly positive anti-histone antibody of 5.4U. A diagnosis of drug-induced lupus was made, hydralazine was stopped and a course of steroids was started. The patient was discharged and returned to clinic a week later with complete normalization of her CXR (Fig. 2). DISCUSSION: This case highlights a potential pitfall of confirmation bias in medical cognitive decision making. The patient's prior history and current presentation was entirely consistent with CHF. The exudative nature of the effusions as well as the presence of a pericardial effusion are both uncommon in CHF and therefore contradictory evidence, which could've easily been dismissed. Hydralazine-associated DIL can occur months to years after exposure(2). Given the frequency of DIL in patients on hydralazine- up to 10% in some series-, a low threshold of suspicion is necessary. Anti-histone antibodies are positive in up to 95% percent of DIL cases overall and should be obtained once DIL is clinically suspected (1, 3). CONCLUSIONS: Hydralazine-associated DIL may present with isolated pleuritis. Symptoms have been shown to improve following discontinuation of the medication and thus recognizing DIL early is of utmost importance. REFERENCE #1: Borchers AT, Keen CL, Gershwin ME. Drug-induced lupus. Ann N Y Acad Sci. 2007 Jun;1108:166-82. eng. doi:10.1196/annals.1422.019. Cited in: Pubmed; PMID 17893983. REFERENCE #2: Cameron HA, Ramsay LE. The lupus syndrome induced by hydralazine: a common complication with low dose treatment. Br Med J (Clin Res Ed). 1984 Aug 18;289(6442):410-2. eng. doi:10.1136/bmj.289.6442.410. Cited in: Pubmed; PMID 6432120. REFERENCE #3: Atzeni F, Marrazza MG, Sarzi-Puttini P, Carrabba M. [Drug-induced lupus erythematosus]. Reumatismo. 2003;55(3):147-54. Lupus indotto da farmaci. ita. doi:10.4081/reumatismo.2003.147. Cited in: Pubmed; PMID 14513113. DISCLOSURES: No relevant relationships by Mery Deeb No relevant relationships by Kamran Manzoor No relevant relationships by Raveena Midha No relevant relationships by Rachel Moody No relevant relationships by Frank Schembri No relevant relationships by Milana Shturman
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