A 62-year-old woman comes to the office due to a weeklong history of brief episodes of sharp chest pain that worsen with deep inspiration. She has had no cough or dyspnea but has had fatigue and stiffness and pain in the hands and knees. Medical history is significant for obesity, hypertension, and nonischemic cardiomyopathy with a left ventricular ejection fraction of 40%. She has a history of intolerance to angiotensin system inhibitor therapy. Medications include carvedilol, furosemide, hydralazine, and isosorbide mononitrate. Her medications were adjusted 6 months ago. She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.8 C (100 F), blood pressure is 134/78 mm Hg, and pulse is 74/min and regular. Physical examination shows nondistended jugular veins and no heart murmurs. Lung auscultation reveals no crackles, but an inspiratory rub is present. There is moderate swelling and tenderness of the hand and knee joints bilaterally. No rash is present. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 62-year-old woman comes to the office due to a weeklong history of brief episodes of sharp chest pain that worsen with deep inspiration.  She has had no cough or dyspnea but has had fatigue and stiffness and pain in the hands and knees.  Medical history is significant for obesity, hypertension, and nonischemic cardiomyopathy with a left ventricular ejection fraction of 40%.  She has a history of intolerance to angiotensin system inhibitor therapy.  Medications include carvedilol, furosemide, hydralazine, and isosorbide mononitrate.  Her medications were adjusted 6 months ago.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37.8 C (100 F), blood pressure is 134/78 mm Hg, and pulse is 74/min and regular.  Physical examination shows nondistended jugular veins and no heart murmurs.  Lung auscultation reveals no crackles, but an inspiratory rub is present.  There is moderate swelling and tenderness of the hand and knee joints bilaterally.  No rash is present.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d528_a3e6_bc81_0f66a7116a84_MD0003_00 This patient likely has drug-induced lupus erythematosus from hydralazine use. Drug-induced lupus erythematosus can be diagnosed if at least one lupus erythematosus criterion occurs after initiation of certain medications; the presentation most commonly includes arthralgia, fever, or serositis, as seen in this patient with new pleuritic chest pain and pleural rub (indicating serositis). Compared with systemic lupus erythematosus, drug-induced lupus erythematosus produces more abrupt symptom onset, is less likely to involve the skin, and affects men and women of any age. Hydralazine, often combined with nitrates for the treatment of heart failure in angiotensin system inhibitor-intolerant patients, is strongly linked to drug-induced lupus erythematosus (frequency ≤20%). Other medications linked to drug-induced lupus erythematosus include procainamide, minocycline, tumor necrosis factor-alpha inhibitors, and isoniazid. Lupus-like symptoms may be related to autoantibodies induced by these drugs (eg, antinuclear antibodies, antihistone antibodies). Patient risk factors include prolonged use (>3 months) and slow acetylator status. Treatment includes stopping the causative medication and treating symptoms (eg, nonsteroidal anti-inflammatory drugs). (Choice B) Granulomatosis with polyangiitis is a necrotizing, small-vessel vasculitis that can cause acute-onset fever and tracheopulmonary disease. However, isolated pleuritis (without cough or dyspnea) and synovitis are uncommon. Additionally, the typical findings of rhinosinusitis, hematuria, and rash (eg, palpable purpura) are not present in this patient. (Choice C) Hypertrophic osteoarthropathy is a syndrome associated with underlying lung disease (eg, adenocarcinoma, chronic pulmonary infection) and can cause arthralgia. However, it classically causes skin thickening and digital clubbing; a history of chronic, insidious symptoms (rather than this patient's acute pleuritis) would be expected. (Choice D) Polyarticular gout can occur as a late complication of untreated gout, or may manifest as a symptom of a myeloproliferative disorder. Although polyarticular gout can cause acute-onset arthralgia, pleuritic chest pain and an inspiratory rub would not be likely. (Choice E) Pulmonary embolism can cause acute-onset dyspnea and pleuritic chest pain, but an inspiratory rub or arthralgia is unlikely. Educational objective: Drug-induced lupus erythematosus should be suspected in patients developing acute onset of fever, arthralgia, and serositis after initiation of causative medications. Hydralazine is strongly associated with drug-induced lupus erythematosus. Treatment includes cessation of the causative medication and symptom management. References: Hydralazine-induced lupus: maintaining vigilance with increased use in patients with heart failure. (http://www.ncbi.nlm.nih.gov/pubmed/16466117) Hydralazine induced lupus and Sweet's syndrome. Report and review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/2193156) Hydralazine-induced lupus erythematosus. (http://www.ncbi.nlm.nih.gov/pubmed/28722919) Drug-induced lupus: an update. (http://www.ncbi.nlm.nih.gov/pubmed/20656071)

A 62-Year-Old Woman Comes to the Office Due to a Weeklong