Arthritis, photosensitivity, and facial rash in an African-American woman are consistent with systemic lupus erythematosus (SLE). The most common cardiovascular syndrome associated with SLE is pericarditis.
SLE is a multisystem inflammatory disease. Pericarditis is a common manifestation of SLE. Pericarditis presents as severe, constant chest pain radiating to the shoulders, arms, and back. The pain is pleuritic and postural (relieved by sitting up and leaning forward). Auscultation of pericarditis will reveal a pericardial friction rub.
Gill et al. review that the antinuclear antibody (ANA) titer is the primary laboratory test used to diagnose SLE. However, because the prevalence of SLE is low in the general population, ANA has a low predictive value in patients without typical clinical symptoms and it should only be obtained in patients with unexplained involvement of two or more organ systems. While an ANA titer of less than 1:40 usually rules out SLE, patients with persistent, characteristic multisystem involvement may be evaluated for possible ANA–negative disease.
The American College of Rheumatology (ACR) criteria for classification of SLE has 85% sensitivity and 95% specificity for SLE when any 4 or more of 11 criteria are noted serially or simultaneously in an individual patient. The criteria include: malar rash, discoid lupus, photosensitivity, oral or nasopharyngeal ulcers, nonerosive arthritis, pleuritis OR pericarditis, renal involvement (usually proteinuria), seizures OR psychosis, hematologic disorder, immunologic disorder, and positive ANA.
Illustration A is an example of a malar rash. Note the sparing of the nasolabial folds.
Illustration B is an example of discoid lupus, erythematous raised patches with adherent keratotic scaling.
Illustration C is an ECG showing pericarditis. Notice the ST elevation in all leads and PTa depression in the precordial leads (depression between the end of the P-wave and the beginning of the QRS-complex).
Answer 1: The pleuritic pain of pericarditis worsens with inspiration.
Answer 3: High-pitched diastolic murmur is consistent with aortic regurgitation.
Answer 4: A displaced apical impulse is consistent with cardiomegaly.
Answer 5: A mid-systolic click is consistent with mitral valve prolapse.
Gill JM, Quisel AM, Rocca PV, Walters DT. Diagnosis of systemic lupus erythematosus. Am Fam Physician. 2003 Dec 1;68(11):2179-86. Review. PubMed PMID: 14677663.
PMID:14677663 (Link to Abstract)
Guidelines for referral and management of systemic lupus erythematosus in adults. American College of Rheumatology Ad Hoc Committee on Systemic Lupus Erythematosus Guidelines. Arthritis Rheum. 1999 Sep;42(9):1785-96. PubMed PMID: 10513791.
PMID:10513791 (Link to Abstract)
USMLE World Step 1 QBank Question #1040. Copyright © USMLEWorld, LLC 2012.