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Valvular heart disease is the most important cardiac manifestation of systemic lupus erythematosus (SLE).
However, severe mitral valve regurgitation necessitating valvular surgery due to SLE is rare. We report a
22-year-old male patient presenting with symptoms of congestive heart failure initially in whom lupus and severe
mitral valve regurgitation were diagnosed. In our patient, four of the American College of Rheumatology
diagnostic criteria for SLE were present, including serositis, hematological abnormalities, positive ANA (640X),
and positive double-stranded DNA (640X). This patient eventually underwent mitral valve surgery with good
clinical results. Pathological examination of the excised mitral valve leaflet showed degenerated valve with
chronic inflammatory cell infiltration which was consistent with Libman-Sacks endocarditis. It serves as a
reminder that SLE (even in a male patient) may be an underlying cause for the development of severe mitral valve
regurgitation.
Key Words:
INTRODUCTION
CASE REPORT
Figure 1. Transthoracic echocardiography obtained on admission. In a parasternal long-axis view (A), an echolucent space posterior to the LV
posterior wall and pericardium, fibrinous stranding within the echo-free space and late systolic displacement (bowing) of mitral leaflets toward the
left atrial side are shown. An apical four-chamber view (B) showed eccentric mitral regurgitation jet toward the left atrial posterior wall.
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DISCUSSION
Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects young women. The
diagnosis of SLE requires four or more of the American
College of Rheumatology criteria. In our patient, the diagnosis of SLE was based on the following criteria:
serositis, haematological abnormalities, positive ANA,
and positive double-stranded DNA.
In patients with SLE, the clinical expression of the
musculoskeletal and mucocutaneous disease predominates, even in patients with cardiovascular disease.1
However, in our case, there were no musculoskeletal and
mucocutaneous presentations clinically. He had in fact
presented with symptoms of congestive heart failure,
which was the sequela of severe mitral regurgitation.
According to the literature, the prevalence of cardiovascular involvement in patients with SLE has been
estimated to be more than 50%. Valvular involvement is
the most commonly encountered form of heart disease
in SLE. Thickening of the valves is encountered more
frequently (51~52%) than valve masses/vegetations
(34~43%). 2 Functionally, valvular regurgitation has
been reported to occur in up to 74% of patients, 7~41%
of cases having moderate or severe regurgitation, while
Figure 4. Photomicrography of the excised mitral valve: (A) Degeneration with an increase of myxoid connective tissue. (Hematoxylin-eosin stain,
20X). (B) Fibrin deposition on the surface of the valve which may be consistent with disrupted vegetation.
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REFERENCES
1. Roldan CA. Valvular disease associated with systemic illness.
Cardiol Clin 1998;16:531-50.
2. Roldan CA, Shively BK, Crawford MH. An echocardiograpic
study of valvular heart disease associated with systemic lupus
erythematosus. N Engl J Med 1996;335:687-706.
3. Moder KG, Miller TD, Trzelaar HD. Cardiac involvement in
systemic lupus erythematosus. Mayo Clin Proc 1999;74:275-84.
4. Shapiro RF, Gamble CN, Wiesner KB. Immunopathogenesis of
Libman-Sacks endocarditis: assessment by light and immunofluoresent microscopy in two patients. Ann Rheum Dis 977;36:
508-16.
5. Ford PH, Ford SE, Lillicrap DP. Association of lupus anticoagulant
with severe valvular heart disease in SLE. J Rheumatol 1988;15:
597-600.
6. Cervera R, Font J, Pare C, et al. Cardiac disease in systemic lupus
erythematosus: prospective study of 70 patients. Ann Rheum Dis
1992;51:156-9.
7. Doherty NE, Siegel RJ. Cardiovascular manifestations of
systemic lupus erythematosus. Am Heart J 1985;110:1257-65.
8. Bulkley BH, Roberts WC. The heart in systemic lupus erythematosus and the changes induced it by corticoid steroid: a
study of 36 necropsy patients. Am J Med 1975;58:243-64.
9. Hakim JP, Mehta A, Jain AC, et al. Mitral valve replacement and
repair. Tex Heart Inst J 2001;28:47-52.
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Case Report
22
American College of
Rheumatoloy (ANA:640X)
(anti-dsDNA:640X)
Libman-Sacks
()
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