Back from the Brink: Catastrophic Antiphospholipid Syndrome

PRESENTATION Cardiogenic shock was the first sign of a devastating disorder in a 27-year-old woman with multiple medical problems. She presented to an outside hospital after 2 days of nausea, epigastric pain, and worsening dyspnea on exertion. Her medical history included systemic lupus erythematosus, autoimmune hepatitis, immune thrombocytopenia, autoimmune hemolytic anemia, attention deficit hyperactivity disorder, anxiety, and migraines. On physical examination, the patient appeared to be in severe respiratory distress. She was afebrile with blood pressure of 100/67 mm Hg, a heart rate of 116 beats per minute, and a respiratory rate of 30 breaths per minute with an oxygen saturation of 100% on supplemental oxygen delivered by a non-rebreather mask. She had no jugular venous distention. On cardiac auscultation, her heart rate was fast and regular with a holosystolic murmur, most prominent at the apex, and an S3 gallop was present. Rales were evident on auscultation of bilateral lung bases. Her extremities were cold with no edema. An electrocardiogram showed sinus tachycardia at 115 beats per minute, low voltage in the anterior leads, and nonspecific ST-T wave changes (Figure 1). Chest radiography revealed bilateral perihilar infiltrates compatible with pulmonary edema. A complete blood count and comprehensive metabolic panel disclosed leukocytosis (total white blood cell count, 42.1 10 cells/mm), anemia (hemoglobin, 10.6 g/dL), thrombocytopenia (platelet count, 135,000/mm), elevated aspartate