Abstract 10429: When You Hear Hoofbeats, Think Zebras and Not Horses: A Case of Cardiac Tamponade Preceding the Diagnosis of Rheumatoid Arthritis

Abstract

Introduction: We present a case of a 50 year-old man who presented with one week of chest discomfort and ECG consistent with pericarditis (Fig. 1A) complicated by pericardial effusion. He rapidly developed cardiac tamponade with a pulsus paradoxus of 30mmHg and associated echocardiographic signs including RV diastolic collapse (Fig. 1B) and severe respiratory variation requiring pericardiocentesis (Fig. 1C). He was treated with high-dose indomethacin and colchicine 0.6mg twice daily with symptomatic improvement. Initial work-up for the etiology of pericardial effusion was notable for a borderline ANA of 1:40 and an RF of 20 IU/mL. CRP improved from 115.5 mg/L to 6.3mg/L with treatment. Two months later, he developed recurrent chest pain with new arthralgias and new morning stiffness in several joints after completing the course of indomethacin. A repeat ECG revealed normal sinus rhythm. He was restarted on high-dose indomethacin and referred to rheumatology clinic for further autoimmune work-up. This revealed an elevated anti-cyclic citrullinated peptide antibody IgG titer (>250), which is highly specific for RA. He was started on methotrexate 15mg weekly for treatment of newly diagnosed RA. To date, he remains asymptomatic. Results: Conclusions: Cardiac tamponade as the initial presentation of RA has not been previously described, but has been seen in systemic lupus erythematosus. Few case reports of pericardial disease without tamponade as the initial finding of RA have been reported. Development of cardiac tamponade in RA is rare (<1%). New clinical symptoms and a high index of suspicion should prompt repeat and expanded work up for rheumatologic etiologies of pericardial disease. While cardiac involvement in RA is known to increase mortality, outcomes have been improving due to novel anti-inflammatory therapies. This case serves as an example of the collaboration needed between specialties to make the correct diagnosis in cardio-rheumatology patients .