Atrial Fibrillation With Rapid Ventricular Response in Pediatric Lupus Carditis Following Pulse Steroid Therapy

Document Type

Conference Proceeding

Publication Date

5-2024

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Introduction: Arrhythmias are a rare manifestation of pediatric lupus carditis, however extensively described in adult systemic lupus erythematosus (SLE). Pulse steroid dosing is a risk factor for atrial fibrillation (Afib) in both pediatric and adult populations. The constellation of children with lupus carditis developing Afib after pulse steroids has rarely been reported. We present the first reported pediatric patient with lupus carditis, developing narrow-complex tachyarrhythmia and AFib after pulse steroids. Case: A 16-year-old male presented with four weeks of nausea, vomiting, and diarrhea, noted to have hypertension. Labs showed pancytopenia, hematuria, proteinuria, acute kidney injury (AKI), elevated Anti-dsDNA and ANA. Echocardiogram revealed pericardial effusion. His AKI progressively worsened, and renal biopsy revealed lupus nephritis, necessitating three doses of daily 1000mg intravenous methylprednisolone. Following steroid therapy, he reported palpitations and electrocardiography showed premature atrial contractions, followed by accelerated junctional rhythm with a ventricular rate of 78 beats/minute (bpm) that evolved to Afib with RVR at 170 bpm. He received rate control with beta-blockers, was transferred to the pediatric ICU, eventually needing cardiac pacing with resolution of arrhythmia. Discussion: The incidence of pediatric SLE is estimated to be 0.3 to 2.2 per 100,000 children-years, accounting for about 20% of SLE burden. In adult populations, SLE is an independent risk factor for developing Afib. Prevalence of AFib under 30 years is estimated at 0.05% and associated with congenital, structural heart disease and channelopathies. Pediatric lupus carditis commonly presents as pericarditis, myocarditis, or endocarditis, but limited case reports have described sinus node dysfunction and tachyarrhythmias. Pulse steroid therapy, by increasing arrhythmogenic potential may cause heart block, idioventricular rhythm, Afib, and sudden cardiac death. The management of pediatric Afib includes cardiology consultation, pharmacological therapy, and possible need for anti-coagulation. If RVR cannot be controlled medically, escalation of care to atrial pacing and cardioversion may be warranted in patients with hemodynamic compromise. Long-term therapy may not be indicated for Afib triggered by pulse steroids in structurally normal hearts, as the lack of long-term steroid exposure decreases the potential for further ectopy. Conclusion: This is the first reported case of a pediatric patient with narrow-complex tachyarrhythmia— AFib with RVR in the setting of lupus carditis and pulse steroid therapy, both factors contributing to arrhythmia and ectopy. Given the high morbidity of patients presenting with AFib with RVR following pulse steroids, pediatric providers should be aware of the urgency for early diagnosis and treatment to prevent adverse outcomes.

Volume

209

Issue

Suppl

First Page

A1729

Comments

International Conference of the American Thoracic Society, May 17-22, 2024, San Diego, CA

DOI

10.1164/ajrccm-conference.2024.209.1_MeetingAbstracts.A1729

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