A 50-year-old woman (XY) presented to the emergency department (ED) at a national health service (NHS) hospital trust in England, following several days of shortness of breath, which had suddenly worsened over the previous hour with the patient having increased palpitations. The patient was admitted as she was dyspneic, using accessory muscles of respiration, respiratory rate was 17 breaths per minute, and oxygen saturation was 99% in air. The trachea was central, but on auscultation, breath sounds were absent in the left upper zone. Her body temperature was not raised. She was hemodynamically stable; her blood pressure was 115/74 mmHg, and her pulse rate was 56 bpm. Of note, the patient was double vaccinated against COVID-19 and had also received a booster. XY had been discharged from another NHS hospital trust 10 days prior, after a similar episode of chest pain and dyspnea, diagnosed as myopericarditis with pericardial effusion. This was attributed to a recent COVID-19 infection, three months before her first admission. The past medical history was significant for complex post-traumatic stress disorder, mixed depression and anxiety, drug-induced lupus erythematosus, and recent calculus cholecystitis.
An initial chest radiograph demonstrated a left upper zone pneumothorax, which occupied about 20% of the volume of the left hemithorax. There was no mediastinal shift or signs of tension. There were however some consolidative changes at the base of the left lung, believed to be related to the preceding COVID-19 infection (Figure 1).
The full blood count was largely unremarkable, no neutrophilia, and normal hemoglobin and platelets. Electrolytes were normal as were the liver function tests (GGT of 58 mumol/L). Coagulation screen was also normal. Troponin T was slightly raised at 26 ng/L; C-reactive protein level was measured on 3rd day of admission and was marginally raised at 6 mg/L. Measurements for Complement components 3 and 4 (C3/C4), anti-dsDNA and ESR were within normal ranges. The patient was negative for HIV, hepatitis B/C, and TB. A computed tomography (CT) thorax confirmed the X-ray findings of pneumothorax and consolidation (Figures 2(a) and 2(b)). There were a few small cysts in the right upper and lower lobes but no generalized bullae. A small pericardial effusion was seen (Figures 2(c) and 2(d)). There was no evidence of cardiomegaly.
An ECG revealed normal sinus rhythm with frequent ectopic beats. An echocardiogram demonstrated normal heart anatomy and filling dynamics. XY displayed the unique butterfly rash associated with SLE.