Leaky valve in SLE

Dr Asish Vijayaraghavan ,
Dr T P Antony , Dr Paul T Antony ,
Dr Rajesh Gopinath
 History
• 29 yr old female

• Ulcer left foot dorsum x 2 weeks

• Fever x 2days

• Diarrhoea x 2 days
 Past history
• H/O recurrent leg ulcers, cutaneous lesions, arthritis for 6
yrs

• Married with h/o two abortions

• Diagnosed as SLE (details unavbl)

• Was initial on allopathy treatment. Now on ayurvedic

topical medication
 On Examination
• Drowsy, disoriented

• Infected ulcer – dorsum of left foot

• Temp : 100 F

• Pulse -100/’ - RR – 24/’

• BP –UL-110/70mmHg

• No pallor , Icterus , Cyanosis , Clubbing , Lymphadenopathy ,

Oedema
 On Examination
• Examination of Cardiovascular system
– JVP –Not raised
– S1S2 n
– Ejection systolic murmur: aortic area
– Early diastolic murmur: aortic area

• Examination of CNS
– Conscious disoriented
– Moving all 4 limbs
– No neck stiffness
– Plantar B/L flexor
– No Bruit
– Fundus Exmn – normal
 On Examination
• Examination of Respiratory system
– NVBS;Chest clear

• Examination of GIT
– No HSM
– BS+
 Provisional diagnosis
• Infected foot ulcer-Sepsis
• Dyselectrolytemia
• ? SLE
• ? APLA Syndrome
 Investigations
• Hb – 11.6
• N 74 L 24 E 2
• E S R – 67 mmhr
• T C -14,400
• P L T – 1.69
• Urea – 12
• S.creatinine -0.8
• S.Sodium – 120
• S. Potassium - 5
• LFT –WNL
• URE –WNL
• TSH – 2.96
• Blood c/s – NO Growth( repeated 7 times)
• Pus c/s – staph aureus
• ANA+ve (3.34) (n range <1)
• Anti dsDNA +ve(166IU)
• S.C3 Low(69mg/dl)(n 90-180)
• Anti Cardiolipin Ab –ve 7.8 (n<12)
• Lupus anticoagulant –ve 3.4(n<12)
• HIV –ve
 Treatment
• IV Antibiotics – Amoxycillin +Clavulinic
acid
- Piperacillin tazobactum

• Electrolyte correction

• Stress dose steroids

 CT Brain
• Atrophic changes in brain
ECHO
ECHO – vegetation in aortic valve
Aortic stenosis and aortic regurgitation
 `

• Possibility of Infective Endocarditis was

considered

• Antiobiotics changed to inj Ceftriaxone and

Gentamicin
 Course of illness
• Low grade fever persisted

• Impaired cognition

• Acute onset weakness of all 4 limbs(B/L

Extensor Plantar)
Temperature chart
MRI BRAIN
MRI BRAIN
MR venogram
 MRI Brain
• Multiple T2 and T2 FLAIR hyperintensities
involving the cortex and subcortical white
matter of bilateral fronto parieto occipital
regions and both cerebellar hemispheres with
diffusion restriction – Acute Infarcts secondary
to vasculitis.
• In view of negative blood cultures, persisting
fever, and persisting altered mental status
with quadriparesis in the background of SLE
the possibility of NBTE , CNS Lupus and APS
was considered.
 Treatment
• Anti platelets

• IV Methyl Prednisolone

• IV Cyclophosphomide
 Outcome
• Symptomatically better

• Afebrile

• Sensorium improved

• Muscle power improved

• Ulcer healed
Temperature chart
 ECHO

• No vegetations

• Severe AR
 Final diagnosis
• SLE – 20APLA

• CNS LUPUS

• NBTE(Libman sachs endocarditis)

 Non Bacterial Thrombotic
Endocarditis
• Endothelial injury and hypercoagulable state

• Atrial surface of mitral valve and ventricular suraface

of aortic valve

• Endothelial injury occur due to

– High velocity jet striking the endothelium
– Flow from a high to low pressure chamber
– Flow across a narrow orifice at high velocity
 Take home messages
• Suspect APS in SLE in order to prevent various
thromboembolic events.

• Non Bacterial Thrombotic Endocarditis is a

possibility in SLE and it can involve the Aortic
Valve

• High index of suspicion , early diagnosis and

prompt treatment in case of CNS vasculitis can
lead to marked improvement in symptoms and
considerable reduction in morbidity.