A large chronic pericardial effusion in an ultramarathon runner with anti-CCP positive rheumatoid arthritis

Abstract

Pericardial effusions arise as an extra-articular manifestation of rheumatoid arthritis (RA). Pericardial effusions are often asymptomatic, particularly in the early phase, but patients are at risk of cardiac tamponade as the effusion progresses. We discuss the case of a 40-year-old male ultramarathon runner with RA who presented with mild pleuritic chest pain and exertional dyspnoea after a recent long-haul flight. Despite a relative tachycardia, his observations were otherwise unremarkable. His blood tests revealed a C-reactive protein (CRP) of 86 mg/L and an anti-cyclic citrullinated peptide (anti-CCP) titre of 360 units/mL. He was initially diagnosed with a pulmonary embolism; however, a large pericardial effusion was found incidentally on CT pulmonary angiogram with over 1500 mL subsequently drained. The patient's symptoms resolved and CRP normalised 2 weeks later. This unique case illustrates that physically fit patients may physiologically compensate for large pericardial effusions and that arthritic symptoms do not correlate with the severity of extra-articular features in RA.

Pathogenesis of Extraarticular Manifestations in Rheumatoid Arthritis—A Comprehensive Review

“…On the other side, IL-6 has a well-known role in RA joint inflammation [57]. Furthermore, ACPAs share similarities to antibodies against fibronectin and vimentin found in inflammatory myocarditis in animal models, suggesting that, either directly via citrullinated proteins (as already suggested in the previous subheading) or via cross-reactivity to similar proteins, could lead to an inflammatory response of the myocardium and consequently to exudative effusion [77,79,135]. On the other hand, not only inflammation, but hemodynamic effects of lower oncotic pressure as a result of decreased albumin levels in RA patients could also be important in effusion pathogenesis, especially for asymptomatic ones as it was found that hypoalbuminemia was a significant variable linked to asymptomatic rheumatoid pericardial effusion [127].…”

“…•Rheumatoid pleural, pericardial, meningeal inflammation share mutual features and similarity to rheumatoid joint inflammation[125,129,131]• Locally produced RF, immunocomplexes leading to complement activation, ↑Il-6, ↑TNF-α [129,131] • Serosal effusion caused by ↓albumin level leading to ↓oncotic pressure [127]•ACPA leading to myocardial inflammation and exudation in pericardium[77,79,135] …”

Pericardial Effusion as a First Manifestation of Rheumatoid Arthritis: A Case Report

“…Most patients are asymptomatic; at most, 10% have the symptoms of pericarditis [ 3 ]. Additionally, if the anti-cyclic citrullinated peptide titer strands are elevated, the patient is at risk of developing pericardial effusion [ 4 ]. Sometimes, a patient can mask pericardial effusion symptoms when they are physically fit [ 4 ].…”

“…Additionally, if the anti-cyclic citrullinated peptide titer strands are elevated, the patient is at risk of developing pericardial effusion [ 4 ]. Sometimes, a patient can mask pericardial effusion symptoms when they are physically fit [ 4 ]. Pericarditis was associated with disease activity in RA [ 5 ].…”