A 24-year-old female patient with systemic lupus erythematosus (SLE) nephritis was admitted to the nephrology department.
Approximately 3 days ago, the patient complained of retrosternal pain. Considering the patient’s emaciated physical condition, gastroesophageal reflux, the most common cause of retrosternal pain, was initially suspected, and omeprazole was given for two days without symptom relief.
Further symptom inquiry revealed pain aggravated by breathing, raising suspicion of lupus pleuritis (pleural involvement is common in SLE, with an incidence as high as 93% in autopsy case series, presenting as pleuritic chest pain with or without pleural effusion[1]). A chest CT scan was performed and showed no significant pleural effusion.
Although pleuritis is an important cause of chest pain in SLE patients, pain originating from muscles, connective tissue, or costochondral joints (costochondritis or Tietze syndrome) is also common. This type of chest pain is characterized by pain during deep breathing, worsening with activity or changes in position (especially during sleep), and tenderness on palpation of the painful area. Patients can be reassured that this pain does not indicate lung involvement.[1:1]
Further inquiry revealed pain aggravated by forward bending, raising the question of pericardial effusion.
Chest pain due to acute pericarditis usually has a sudden onset and is located in the anterior chest. Unlike myocardial ischemic chest pain, pericarditis-related chest pain is typically pleuritic and sharp, worsening with inspiration or coughing. One of the most notable features is that pain tends to lessen when the patient sits up and leans forward. This position usually relieves pressure on the parietal pericardium (especially during inspiration) and may also help limit diaphragmatic movement. Chest pain that radiates to the trapezius ridge is also a highly specific sign of pericarditis. Some patients may have dull, pressing pain, making it harder to differentiate pericarditis from other causes of chest pain.[2]
However, in some patients, pleuritic chest pain and pericarditis may be the initial manifestations of systemic lupus erythematosus (SLE).[2:1]
An echocardiogram on admission indeed showed a small amount of pericardial effusion. Follow-up ultrasound demonstrated an increase from a minimal to a small amount of effusion.
After one day of intravenous steroid infusion, the chest pain was relieved. Considering the ultrasound findings and therapeutic response, the chest pain was attributed to pericarditis. A follow-up echocardiogram to assess pericardial effusion volume was planned.
Reconsideration
Apart from lupus pericarditis, the patient has been on long-term immunosuppressants. Is tuberculous pericarditis also possible? Therefore, tuberculosis antibody testing was added.
Reflection
The differential diagnosis of chest pain includes many causes, each with characteristic features. Due to limited internal medicine knowledge, I could only think of a few and will continue to supplement relevant notes later.
- Cardiovascular: acute coronary syndrome, aortic dissection, cardiac tamponade
- Respiratory: pneumothorax
- Musculoskeletal