Challenging cases in rheumatic pregnancies

Bilateral Deep Vein Thrombosis (DVT) as a Harbinger of Lung Adenocarcinoma: A Rare Presentation

Oncologic disorders, such as lung adenocarcinoma, can intricately interplay with the coagulation cascade, often leading to thromboembolic events, of which deep vein thrombosis (DVT) stands out prominently. In this report, we present a unique case of a 50-year-old non-smoking Jordanian male who exhibited bilateral DVT as an unexpected preliminary manifestation of an aggressive lung adenocarcinoma. Although the patient did not possess common risk factors for DVT, the bilateral presentation drew attention to the possibility of an underlying malignancy. Subsequent investigations revealed a stage 4 primary lung adenocarcinoma. This case underscores the imperative of maintaining a broad differential in cases of DVT, especially when presenting bilaterally and without evident etiology. Such early detection and intervention, accompanied by collaborative medical strategies and specialized care, can play a pivotal role in enhancing patient prognosis and survival rates. This case exemplifies the potential of DVT, particularly when bilateral, as a harbinger of a more sinister underlying pathology like lung adenocarcinoma.

Impact of pregnancy in patients with systemic lupus erythematosus-associated pulmonary arterial hypertension: case series and literature review

Objective

This study aimed to investigate the clinical characteristics and outcomes of pregnancy complicated by SLE-associated pulmonary arterial hypertension (SLE-PAH) in a case series and literature review.

Methods

This single-centre retrospective study included 10 consecutive pregnancies complicated by SLE-PAH confirmed by right heart catheterisation (RHC) at Peking Union Medical College Hospital between 2009 and 2020. A literature search was conducted and 14 pregnancy cases complicated by SLE-PAH were reviewed.

Results

At the time of 10 patients’ initial visits, the average age was 30.00±5.72 years and the median disease duration of SLE and PAH was 34.5 (range 1–164) months and 2 (1–51) months. Two patients carried planned pregnancy, seven patients developed PAH during pregnancy and one pregnancy was unplanned. Further, nine patients had low disease activity, with Systemic Lupus Erythematosus Disease Activity Index between 0 and 4, and 30%, 30% and 40% of patients were of WHO functional class II, III and IV, respectively. All patients were evaluated by RHC and echocardiography. N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were elevated in 70% of patients, with a median level of 776 (56–18 023) pg/mL. The median time of completed pregnancies in all patients was 31 (15–38) weeks and six patients delivered live infants. SLE activity and PAH severity improved in 70% of patients within 6 months after delivery. One patient died on the 15th day after induction of labour. In the remaining patients, all achieved a lupus low disease activity state; according to the European Society of Cardiology/European Respiratory Society risk stratification, seven were categorised at a lower risk state compared with their risk stratification during pregnancy, and two remained at intermediate risk. Additionally, 80% of patients exhibited mild impairments with WHO functional class I or II. The median NT-proBNP level was 184 (32–4003) pg/mL within 6 months after delivery. In the reviewed literature, the average age of patients was 30.09±5.37 years. The median time of completed pregnancies was 36 (28–40) weeks. More cases were planned and successful, and the survival rates of mothers and neonates were 85.71% and 92.86%, respectively.

Conclusions

Successful pregnancy could be possible in women with SLE-PAH if SLE-PAH treatment goals are achieved under proper therapies, careful monitoring and thorough evaluations.

Therapeutic Plasma Exchange Improved Pregnancy-associated Thrombotic Microangiopathy but not the Pregnancy Outcome in Patient with Systemic Lupus Erythematosus

Thrombotic microangiopathy (TMA) is a rare but life-threatening complication of systemic lupus erythematosus (SLE) and is associated with adverse pregnancy outcomes. We herein report a 30-year-old pregnant woman with SLE complicated by TMA. Because her condition was unresponsive to initial corticosteroid and fresh-frozen plasma infusion treatment, we attempted plasma exchange (PE). Although thrombocytopenia and microangiopathic hemolytic anemia gradually improved, fetal death was confirmed at 23 weeks of gestation. This case suggests that PE is an effective therapeutic option but might be insufficient to maintain pregnancy in patients with SLE complicated by TMA.