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A3502 - Hemopericardium Causing Cardiac Tamponade in Patient with Autoimmune Disease and Supratherapeutic INR
Author Block: J. Petty1, Y. Shen1, P. Su1, A. C. Boulos2, J. Gordon3; 1Parkview Medical Center, Pueblo, CO, United States, 2Pulmonary and Critical Care Medicine, Parkview Medical Center, Pueblo, CO, United States, 3Pueblo Pulm Associates, Pueblo, CO, United States.
Introduction Hemopericardium causing cardiac tamponade is a rare but can be fatal complication of autoimmune diseases. System lupus erythematous (SLE) and Sjӧgren’s syndrome are known to be chronic inflammatory disorders that commonly cause pericarditis. Pericardial effusions are a rarer complication of these disorders. Case Report Patient is a 60 year old female with PMH significant for SLE, antiphospholipid antibody syndrome and Sjӧgren’s syndrome on chronic anticoagulation with Coumadin who presented to the ED from Coumadin clinic with record of an elevated INR. She complained of dyspnea, bright red blood per rectum with wiping, decreased appetite, dry cough and a sore throat. Patient denied any trauma or injury. She was found to have an INR of 12.9 in the ED and was administered Vitamin K 5mg IVPB. She was initially admitted to the ICU for severe sepsis and an infectious workup was begun. She was fluid responsive and did not require vasopressive support. Her INR improved to 2.5 after Vitamin K administration. After hemodynamic stability was achieved, patient was transferred to the medical floor. Blood cultures remained negative and no infectious source was found. An echocardiogram was ordered to evaluate for cardiac and/or pulmonary involvement of SLE causing her hemodynamic instability. On the 3rd day of admission, patient experienced progressive dyspnea and was found to have a large pericardial effusion with early tamponade physiology on echocardiogram. Cardiology was consulted and patient underwent urgent pericardiocentesis with drain placement that afternoon. An initial amount of 450cc was removed immediately during the procedure. Patient clinically improved after the pericardiocentesis and her dyspnea resolved. Approximately 550cc total of blood was drained from her pericardium. Patient remained hemodynamically stable throughout the rest of her hospital stay. She was restarted on Plaquenil per her Rheumatologist. She was discharged on Coumadin at an INR goal of 2.5-3.5 due to her antiphospholipid antibody syndrome. Discussion Pericardial effusions causing cardiac tamponade are rare complications in SLE with an incidence of less than 2%. Our patient could have rapidly declined if an echocardiogram had not been performed early in her hospital stay. Her pre-existing inflammation associated with her autoimmune diseases likely led to the spontaneous bleed into the pericardial space due to supratherapeutic INR. Consider evaluation for pericardial effusions in hemodynamic unstable patients with autoimmune diseases.