Unmasking Hydralazine-Induced Lupus: Isolated Serositis Leading to Pericardial Window

Document Type

Conference Proceeding

Publication Date

4-7-2026

Publication Title

Journal of the American College of Cardiology

Abstract

BACKGROUND Hydralazine is associated with drug-induced systemic lupus erythematosus (DILE). DILE often mimics idiopathic systemic lupus erythematosus, presenting with fever, musculoskeletal symptoms, and cutaneous manifestations with less organ involvement. Pathogenesis involves disruption of immune tolerance through epigenetic modification and impaired B lymphocyte receptor editing. CASE A 61-year-old female with CKD stage 4, type 2 diabetes mellitus, ischemic cardiomyopathy, and coronary artery disease on long-term hydralazine presented with cellulitis, acute renal failure, and heart failure exacerbation. Imaging revealed bilateral pleural effusion and moderate pericardial effusion, which rapidly enlarged. She underwent thoracotomy with pericardial window and chest tube placement, draining 400 ml of exudative pericardial fluid and 2 liters of pleural fluid. Cultures and cytology were negative. Histopathology showed acute inflammation and fibrinous exudate. Serology demonstrated elevated anti-histone antibody (3.0, strongly positive), positive antinuclear antibody at 1:640, and negative double-stranded DNA. Hydralazine was discontinued, and prednisone, colchicine, and hydroxychloroquine were initiated, leading to clinical improvement and reduced drain output. DECISION-MAKING The rapid progression of pericardial effusion toward tamponade mandated urgent surgical intervention. Negative infectious and malignant studies redirected the focus to autoimmune causes. Strongly positive anti-histone antibody and antinuclear antibody with negative double-stranded DNA supported the diagnosis of DILE. Hydralazine was promptly discontinued, and immunosuppressive therapy was initiated. The patient demonstrated clinical improvement and decreased drain output, allowing removal of the pericardial drain. CONCLUSION Hydralazine-induced lupus should be considered in patients with unexplained serositis, especially those with comorbidities such as CKD and long-term drug exposure. Prompt diagnosis, drug withdrawal, and targeted therapy are crucial to preventing life-threatening complications such as pericardial tamponade.

Volume

87

Issue

13 Suppl

First Page

A1567

Comments

American College of Cardiology 75th Annual Scientific Session & Expo, March 28-30, 2026, New Orleans, LA

Last Page

A1567

DOI

10.1016/j.jacc.2026.02.3923

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