A CASE OF RHUEMATOID ARTHRITIS ASSOCIATED WITH CONSTRICTIVE PERICARDITIS

Sherif A. Nasef, Ali M. AlMuslim, Amer S. Zahralliyali, Hisham S. AlMomen and Alsir G. Ali. Department of Internal Medicine, King Fahad Specialist Hospital-Dammam, Saudi Arabia. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Introduction:-Constrictive pericarditis manifests in less than 10% on rheumatoid arthritis patients. It should be considered in patients with rheumatoid arthritis who develop unexplained cardiac failure. Early diagnosis requires a high index of suspicion and cardiac imaging is necessary to confirm the diagnosis. Medical treatment is largely ineffective and pericardiectomy should be considered.
Case Description:-A 34 years old Saudi male referred to the rheumatology outpatient clinic for management of recently diagnosed rheumatoid arthritis. The patient had 10 months history of pain involving MCP, PIP and wrists joints bilaterally. He also complained of occasional pain involving both elbows, shoulders, knees and ankles. His pain was associated with morning stiffness lasting for one hour.
He denied visual symptoms, oral ulcers, skin rash, nail changes, hair loss or fever.
He also complained of progressive exertional shortness of breath for 3 months with lower limbs swelling. He denied chest pain, cough, palpitations, dizziness, diaphoresis, syncope or presyncope.
He never smoked or consumed alcohol or illicit drugs. He denied any family history of rheumatoid arthritis or any other rheumatic or non-rheumatic diseases.
On examination, he was comfortable at rest with obvious icteric sclera. Temperature: 37.1 C°, Blood pressure of 111/87, pulse of 66 irregularly irregular, RR 20, Oxygen saturation of 100% on room air. Skin exam showed no rash or nodules. Head and neck exam was significant for jugular venous distension of 5 cm above the sternal angle. There were no palpable lymph nodes. Cardiopulmonary exam was significant for irregular variable heart sounds The patient was started on oral furosemide as well as an ACE inhibitor and a beta blocker as anti-failure medications. He was anti coagulated with rivaroxaban. Upon follow up, his shortness of breath and lower limb edema improved remarkably. His BNP decreased to 270 pg/ml and his total bilirubin dropped from 81 to 70 umol/L. Plaquenil therapy was started and Prednisone dose was reduced to 7.5 mg daily.
He was referred for cardiac surgery for the management of his rheumatoid constrictive pericarditis. Pericardiectomy was performed. Pathological exam of the pericardium showed fibrinous constrictive pericarditis with no evidence of infection or malignancy Follow up echocardiogram after surgery showed that left ventricular ejection fraction improved to 50%.

Discussion:-
Constrictive pericarditis can occur in virtually any pericardial disease process e.g. Idiopathic/viral (42-61%), post-cardiac surgery (11-37%), post-radiation therapy primarily in Hodgkin's disease and breast cancer (2-31%), connective tissue disorder (3-7%), post infectious; tuberculous or purulent pericarditis (3 -15%) percent and other miscellaneous causes. 1 Patient with constrictive pericarditis usually present with symptoms and signs of volume overload due to right and left cardiac failure. 2 Several diagnostic tests are available for diagnosis of pericarditis. Chest X-ray occasionally shows pericardial calcification. Trans esophageal echocardiogram is an essential diagnostic test to evaluate constrictive pericarditis. MRI or CT of pericardium is needed to evaluate the patient prior to surgery and are fast tools for diagnosis. Symptoms of constrictive pericarditis are usually permanent and often progressive requiring pericardiectomy. Steroid therapy gives only temporary relief before pericardiectomy. 3,4 Patients with RA occasionally develop constrictive pericarditis requiring pericardiectomy as definitive treatment. Most studies have shown that rheumatoid constrictive pericarditis is commoner in males who tend to have subcutaneous rheumatoid nodules and chest radiograph showing a considerably enlarged heart. 4 Our case is the first in the literature of a patient with rheumatoid arthritis with Severe constrictive pericarditis early in the disease process presenting with right sided heart failure and congestive hepatopathy causing liver cirrhosis within months of diagnosis. Liver cirrhosis precluded the use of methotrexate and Plaquenil and Prednisone were used instead.

Conclusion:-
Pericarditis in rheumatoid arthritis is associated with poor prognosis. This is a rare case of a young patient with constrictive pericarditis associated with RA. There is a growing population of early RA patients with cardiac involvement. Early cardiac screening is thus recommended.