系统性红斑狼疮中抗疟药物诱导性心肌病：是否如认为的那样罕见？

Antimalarial-induced Cardiomyopathy in Systemic Lupus Erythematosus: As Rare as Considered?

机构信息

From the University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases, University Health Network; University of Toronto, Krembil Research Institute; Department of Cardiology, University of Toronto, Women's College Hospital; Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.

K. Tselios, MD, PhD, Clinical Research Fellow, University of Toronto Lupus Clinic, Toronto Western Hospital, Centre for Prognosis Studies in the Rheumatic Diseases; M. Deeb, MSc, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Lupus Clinic, University Health Network; D.D. Gladman, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Co-Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital; P. Harvey, BMBS, PhD, FRACP, Department of Cardiology, University of Toronto, Women's College Hospital; S. Akhtari, MD, FRCPC, Department of Cardiology, University of Toronto, Women's College Hospital; S. Mak, MD, PhD, Mecklinger Family and Posluns Family Cardiac Catheterization Research Laboratory, Department of Medicine, Division of Cardiology, Mount Sinai Hospital, University of Toronto; J. Butany, MBBS, MS, FRCPC, Department of Laboratory Medicine and Pathobiology, University Health Network, Toronto General Hospital; M.B. Urowitz, MD, FRCPC, Professor of Medicine, University of Toronto, Senior Scientist, Krembil Research Institute, Director, University of Toronto Lupus Clinic, Centre for Prognosis Studies in the Rheumatic Diseases.

出版信息

J Rheumatol. 2019 Apr;46(4):391-396. doi: 10.3899/jrheum.180124. Epub 2018 Oct 15.

DOI:10.3899/jrheum.180124

PMID:30323009

Abstract

OBJECTIVE

Antimalarials (AM) are recommended for all systemic lupus erythematosus (SLE) patients without specific contraindications. Their main adverse effect is retinal damage; however, heart disease has been described in isolated cases. The aim of our study is to describe 8 patients with AM-induced cardiomyopathy (AMIC) in a defined SLE cohort.

METHODS

Patients attending the Toronto Lupus Clinic and diagnosed with definite (based on endomyocardial biopsy; EMB) and possible AMIC were included [based on cardiac magnetic resonance imaging (cMRI) and other investigations].

RESULTS

Eight female patients (median age 62.5 yrs, disease duration 35 yrs, AM use duration 22 yrs) were diagnosed with AMIC in the past 2 years. Diagnosis was based on EMB in 3 (extensive cardiomyocyte vacuolation, intracytoplasmic myelinoid, and curvilinear bodies). In 4 patients, cMRI was highly suggestive of AMIC (ventricular hypertrophy and/or atrial enlargement and late gadolinium enhancement in a nonvascular pattern). Another patient was diagnosed with complete atrioventricular block, left ventricular and septal hypertrophy, along with concomitant ocular toxicity. All patients had abnormal cardiac troponin I (cTnI) and brain natriuretic peptide (BNP), whereas 7/8 also had chronically elevated creatine phosphokinase. During followup, 1 patient died from refractory heart failure. In the remaining patients, hypertrophy regression and a steady decrease of heart biomarkers were observed after AM cessation.

CONCLUSION

Once considered extremely rare, AMIC seems to be underrecognized, probably because of the false attribution of heart failure or hypertrophy to other causes. Certain biomarkers (cTnI, BNP) and imaging findings may lead to early diagnosis and enhance survival.

摘要

目的

无特殊禁忌证的系统性红斑狼疮（SLE）患者均推荐使用抗疟药（AM）。其主要不良反应为视网膜损伤，但也有孤立性心脏病病例的报道。本研究旨在描述在明确的 SLE 队列中 8 例 AM 诱导的心肌病（AMIC）患者。

方法

纳入在多伦多狼疮诊所就诊并诊断为明确（基于心内膜心肌活检；EMB）和可能 AMIC 的患者[基于心脏磁共振成像（cMRI）和其他检查]。

结果

在过去 2 年中，8 名女性患者（中位年龄 62.5 岁，疾病持续时间 35 年，AM 使用时间 22 年）被诊断为 AMIC。3 例患者的诊断基于 EMB（广泛的心肌细胞空泡化、细胞内髓样和曲线形体）。4 例患者的 cMRI 高度提示 AMIC（心室肥厚和/或心房增大以及非血管模式的晚期钆增强）。另 1 例患者被诊断为完全性房室传导阻滞、左心室和间隔肥厚，同时伴有眼部毒性。所有患者的心脏肌钙蛋白 I（cTnI）和脑钠肽（BNP）异常，7/8 例患者的肌酸磷酸激酶也持续升高。在随访期间，1 例患者死于难治性心力衰竭。在其余患者中，停止 AM 治疗后，观察到心肌肥厚消退和心脏生物标志物稳定下降。