A Unique Case of Systemic Lupus Erythematosus Myocarditis Complicated by Plasmapheresis-Responsive Cardiogenic Shock

Figures

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  Figure 1. Electron Microscopy of Renal Biopsy Demonstrating Electron-Dense Deposits Along the Glomerular Basement Membrane in Both the Subepithelial and Intramembranous Locations Electron dense deposits (arrows) are detected ultrastructurally along glomerular basement membranes (GBM) in subepithelial and intramembranous locations. E = glomerular endothelial cell; P = podocyte.

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  Figure 2. A Tubuloreticular Inclusion Was Found in a Glomerular Endothelial Cell A tubuloreticular inclusion (arrow) was found in a glomerular endothelial cell. Abbreviations as in Figure 1.

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  Figure 3. Endomyocardial Biopsy Shows Moderate to Marked Myocyte Hypertrophy Without Inflammatory Infiltrates or Myocyte Necrosis (10× magnification) No endothelial swelling, viral inclusions, or toxoplasma inclusions were identified. The direct immunofluorescence for IgG, IgA, IgM, C3, and C1q was negative. Indirect immunofluorescence for C4d was also negative. Immunohistochemical staining for CD4 and CD68 was not performed due to lack of visible lymphocytic or histiocytic inflammation.

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  Figure 4. Cardiac CMR Images Show Biventricular Dilation With Severely Decreased Biventricular Systolic Function (Left Ventricular Ejection Fraction = 23%; Right Ventricular Ejection Fraction = 21%) There was no late gadolinium enhancement to suggest myocardial scarring or fibrosis, infiltration, or inflammation. Findings are most consistent with nonischemic dilated cardiomyopathy.

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  Figure 5. Changes in Left Ventricular Ejection Fraction Responses to Plasmapheresis PLEX = plasmapheresis.