Images In...

Hydroxychloroqine induced dilated cardiomyopathy and lupus mastitis

Abdul Majid Wani¹, Waleed Mohd Hussain², Bothaina Abdul Shakour³, Mohamad Ibrahim Fatani², Amer Mohd Khoujah⁴, Mubeena Akhtar², Abdullah Ahmad Tawakul², Mohd Saleem²

¹ Hera General Hospital, Medicine, 4a/201, Hera General, Hospital, Makkah, 21955, Saudi Arabia
² Hera General Hospital, Medicine, Hera General Hospital, Makkah, Western, 21955, Saudi Arabia
³ Hera General Hospital, Radiology, Hera General Hospital, Makkah, Western, 21955, Saudi Arabia
⁴ Natinal Guard Hospital, Medicine, National Guard Hospital, Jeddha, Western, 21955, Saudi Arabia

Correspondence to:
Abdul Majid Wani, dr_wani_majid{at}yahoo.co.in

We report a unique case of a 26-year-old female patient with systemic lupus erythematosus (SLE), who had been treated with hydroxychloroquine 400 mg/day from the age of 11 years, who presented with congestive cardiac failure. She was treated for heart failure with diuretics and angiotensin converting enzyme (ACE) inhibitors, but deteriorated and was readmitted, this time with the additional finding of pericardial effusion and painful left breast swelling. Echocardiography revealed dilated cardiac chambers with thin wall and septum and minimal pericardial effusion (figs 1 and 2). The patient was evaluated for breast swelling which, on examination, revealed tender, multiple nodular lumps in the left breast, the largest measuring 4 cm x 4 cm (fine needle aspiration cytology of the latter revealed degenerated fat cells and foci of calcification (fig 3); thus, a core biopsy was undertaken to rule out malignancy. A mammogram was also performed and revealed unusual findings consistent with lupus mastitis (fig 4), which was supported by biopsy which revealed panniculitis (fig 3). Since the patient was being evaluated to rule out malignancy, computed tomography (CT) scan of the chest and breast ultrasonography were performed and characteristic findings of lupus mastitis were noted (figs 5 and 6). Immune markers such as antinuclear antibody (ANA) and dsDNA were absent at this time, the latter being a marker of lupus activity, thus supporting the hypothesis that the cardiomyopathy was caused by the hydroxychloroquine. Withdrawal of the drug resulted in a dramatic improvement of the patient, both clinically and radiologically, within 3 months.

View this figure (97K): in this window | in a new window | PowerPoint for Teaching   Figure 1 Echocardiograph showing a thin septum, dilated cardiac chambers, and thin ventricular wall caused by hydroxychloroquine cardiomyopathy.

 

View this figure (117K): in this window | in a new window | PowerPoint for Teaching   Figure 2 Echocardiograph showing dilated ventricular cavity, thinned wall and minimal pericardial effusion.

 

View this figure (143K): in this window | in a new window | PowerPoint for Teaching   Figure 3 Breast biopsy showing panniculitis (fat degeneration, periseptal fibrosis, lymphocyte infiltration). Haematoxylin and eosin.

 

View this figure (116K): in this window | in a new window | PowerPoint for Teaching   Figure 4 Unusual mammogram showing diffuse calcifications in lupus mastitis.

 

View this figure (113K): in this window | in a new window | PowerPoint for Teaching   Figure 5 Computed tomography chest scan showing breast calcifications and minimal pericardial effusion.

 

View this figure (141K): in this window | in a new window | PowerPoint for Teaching   Figure 6 Ultrasonography of left breast showing diffuse calcifications as acoustic shadowing in lupus mastitis.

 

The breast lumps were consistent with lupus mastitis as the mammography findings of diffuse calcifications have been reported in only a few case reports. The cardiotoxicity of antimalarials is well reported in case reports¹ but dilated cardiomyopathy due to hydroxychloroquine is unusual. The unusual echocardiographic images of cardiomyopathy due to hydroxychloroquine as well as the radiological and pathological features of lupus mastitis^2,3 are presented.

We are thankful to Wjiah Anjum and Dr Osama for their support in preparing the manuscript.

Competing interests: none.

Patient consent: Patient/guardian consent was obtained for publication

1. Nord, JE, Shah, PK, Rinaldi, RZ, et al. Hydroxychloroquine cardiotoxicity in systemic lupus erythematosus: a report of 2 cases and review of the literature. Semin Arthritis Rheum 2004; 33: 336–51.[CrossRef][Medline]
2. Georgian-Smith, D, Lawton, TJ, Moe, RE, et al. Lupus mastitis: radiologic and pathologic features. AJR Am J Roentgenol 2002; 178: 1233–5.[Free Full Text]
3. Bachmeyer, C, Goubin, I, Berseneff, H, et al. Coarse calcifications by mammography in lupus mastitis. Arch Dermatol 2006; 142: 398–9.[Free Full Text]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?