In a case series of 2 women, systemic lupus erythematosus initially presented with atypical manifestations such as pericardial tamponade and acute appendicitis, which improved with immunosuppression.
Case Report (n=2)
Systemic lupus erythematosus can initially present with atypical, severe manifestations such as cardiac tamponade or acute appendicitis, requiring a high index of suspicion when infectious workups are negative.
Abstract Introduction Systemic lupus erythematosus (SLE), like many autoimmune conditions, is a master of disguise capable of mimicking infection, malignancy, or surgical emergencies. Early recognition remains challenging, as the disease may present in unexpected organs with atypical features. While joint pain, rash, and fatigue are classic, SLE may first appear in places as diverse as the heart or appendix. We describe two healthy women whose initial manifestations of lupus were far beyond expectation, reminding clinicians that autoimmune disease can be hidden in plain sight. Case 1 - When the Heart Whispered First A 52-year-old woman with hypertension and chronic anemia presented with weakness, dyspnea, and pleuritic chest pain. She was febrile, hypotensive, and tachycardic. Physical examination revealed distant heart sounds. Bedside echocardiography showed a large pericardial effusion with tamponade physiology. Pericardiocentesis drained 1.2 L of serosanguineous fluid, but fevers and effusion persisted despite antibiotics. Infectious workup remained negative. Autoimmune testing revealed ANA 1:1280 and anti-dsDNA positivity. Her symptoms improved with methylprednisolone, anakinra, and hydroxychloroquine. This case highlights that lupus may first reveal itself through the pericardium before any cutaneous or articular involvement. Case 2 - When the Appendix Told the Story A 33-year-old woman with no past medical history presented with fever, dyspnea, and right lower quadrant abdominal pain with guarding and rebound. Imaging showed bilateral pleural effusions and acute appendicitis. Laparoscopic appendectomy revealed appendiceal endometrial tissue. Fevers persisted despite antibiotics, and she developed hypoxia. Repeat imaging showed worsening pleural effusions, and thoracentesis drained exudative fluid. Extensive infectious evaluation was unrevealing. Autoimmune testing demonstrated ANA 1:1500, anti-dsDNA, and anti-SSA/SSB positivity. She improved with corticosteroids and hydroxychloroquine and was discharged on a steroid taper with rheumatology follow-up. What began as appendicitis proved to be lupus in disguise. Discussion Both cases highlight how SLE can masquerade as infection or surgical emergencies. In one, tamponade required emergent cardiac intervention; in the other, presumed appendicitis masked systemic inflammation. These presentations emphasize the value of multidisciplinary collaboration, persistence in diagnostic reevaluation, and considering autoimmune etiologies when clinical puzzles persist despite negative infectious workups. Conclusion SLE may emerge from unexpected organs, such as the pericardium or appendix, before declaring its systemic nature. Clinicians should maintain a high index of suspicion for autoimmune disease in prolonged or recurrent febrile illness. Listening beyond the obvious and trusting clinical intuition can prevent delays and direct life-saving therapy. This abstract is funded by: none
Sekharamahanti et al. (Fri,) conducted a case report in Systemic Lupus Erythematosus (n=2). Immunosuppressive therapy (corticosteroids, hydroxychloroquine, anakinra) was evaluated. In a case series of 2 women, systemic lupus erythematosus initially presented with atypical manifestations such as pericardial tamponade and acute appendicitis, which improved with immunosuppression.