A 29 year old female with a past medical history of systemic lupus erythematosus, diagnosed 15 years earlier, presents with lupus nephritis, currently on peritoneal dialysis. She had myopericarditis in 2012 and is currently on immunosuppressants. The patient began with exertional dyspnea and angina 2 weeks before admission. An echocardiogram was performed, reporting severe mitral and tricuspid insufficiency. Afterwards, the patient presented with resting angina associated with an adrenergic and vagal response. Initially, rheumatology ruled out autoimmune activity caused by lupus. We performed a coronary angiogram based on clinical presentation, EKG changes and biomarkers, finding a trivascular coronary artery disease classified as a Markis I coronary artery ectasia and a coronary dissection of the ramus intermedius and the circumflex, posterior to the first obtuse marginal artery. Cardiothoracic surgery considered intervention with a coronary bridge posterior to the dissection of the intermedius ramus artery, marginal obtuse and posterolateral artery, as well as a mitral valve replacement and a tricuspid valve repair. Coronary dissection is more common in women (70%), clinical presentation varies from unstable angina to sudden death. In lupus nephritis, it is an uncommon form of extra renal vasculitis. Treatment depends on the number of arteries affected, as well as the haemodynamic state of the patient. It is imperative to individualize treatment options.
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