CASE HISTORY

A 30 year old woman with systemic lupus erythematosus (SLE) was admitted to hospital complaining of shortness of breath, orthopnoea, swelling of ankles, and increased weight over the preceding eight days. She otherwise felt well, and reported that her lupus was inactive. She denied any associated chest pain, cough, or fever. A similar presentation had occurred three months previously, when she went to another hospital with the same symptoms, associated with a raised temperature (38.4°C). Investigations performed at that time included a complete blood picture, cardiac enzymes, and the measurement of antibodies against double stranded DNA (dsDNA). Blood and urine cultures were normal and a chest x ray examination was normal. All blood tests were normal with the exception of a raised troponin-t level of 0.62 μg/l (normal <0.1 μg/l). An echocardiogram and high resolution computed tomography (HRCT) chest scan were also done. She was discharged from hospital and given oral diuretics without a definite diagnosis being made. Two weeks later, her case was reviewed in our hospital and in view of the recent history, a repeat chest x ray examination, echocardiogram, and HRCT scan of the chest were performed. The only abnormality was seen on echocardiography, which showed a hypokinetic inferior, inferoposterior, and inferoapical left ventricle wall, with some mild to moderate left ventricular dilatation and systolic dysfunction. There was a small pericardial effusion with no valvular abnormalities and the ejection fraction of the left ventricle was estimated at 43%. Treatment was not altered and she remained stable until the current presentation.

The patient's SLE had been diagnosed 10 years previously, with initial symptoms including alopecia, Raynaud's syndrome, arthralgia, and a photosensitive skin rash. Six years after diagnosis she was diagnosed with WHO …