Management of Cardiac Tamponade During Systemic Lupus Erythematosus Flare with Significant Pericardial Effusion: A Case Report

BACKGROUND Pericarditis is a frequently encountered complication of systemic lupus erythematosus (SLE). However, cardiac tamponade resulting from massive pericardial effusion is a rare sequela. Risk factors for cardiac tamponade in SLE include female sex, reduced serum complement, and positive anti-nucleosome antibody at diagnosis. Management options for cardiac tamponade, such as pericardiocentesis and pericardial window, are tailored to the individual, and clear guidelines for when to proceed with invasive intervention are lacking. CASE REPORT We present a case of cardiac tamponade associated with an SLE exacerbation in a 38-year-old woman, associated with fever, dyspnea, and pleuritic chest pain. A chest radiograph demonstrated a large left pleural effusion obscuring a widened mediastinum suspicious for pericardial effusion. After a trial of medical therapy, the patient developed new atrial fibrillation, hypotension, and tachycardia, and proceeded to pericardiocentesis following which 1.6 liters of pericardial fluid was drained over the following 24 hours. Disease control was achieved with high-dose pulsed corticosteroids and cyclophosphamide and there was no recurrence of the effusion. CONCLUSIONS This appears to be one of the largest volumes of pericardial drainage described in the literature in the setting of SLE. Cardiac tamponade can occur at any stage of the disease course in SLE. Large pleural effusions can mimic symptoms of pericardial effusion and make diagnosis challenging. Definitive management can be achieved using a combination of invasive and medical therapy. Risk factors for the development of cardiac tamponade should be identified early in the course of an SLE exacerbation to ensure prompt treatment and avoid further complications.