Rheumatoid constrictive pericarditis, treated by pericardiectomy report of a case and review of the literature

Abstract

A case of constrictive cholesterol pericarditis with successful pericardiectomy in a patient with rheumatoid arthritis is presented. The relationship between rheumatoid arthritis and constrictive pericarditis is discussed. Twenty-five cases of rheumatoid constrictive pericarditis, including 4 with constrictive cholesterol pericarditis undergoing pericardiectomy are reviewed. In these cases, steroid therapy did not appear to be beneficial, and early pericardiectomy is recommended.T h e association of constrictive pericarditis in a patient with rheumatoid arthritis and the subsequent finding of cholesterol pericarditis at the time of pericardiectomy prompted a review of the literature and this case report. CASE REPORTA 51-year-old white woman entered the hospital on Dec 15, 1967, with a history of orthopnea, recurrent paroxysmal nocturnal dyspnea, ascites, cough, and peripheral edema of 2-3 weeks duration.Rheumatoid arthritis involving the hands predominantly (Fig 1) had been present for 12 years, and was satisfactorily controlled by 5 mg of prednisone every other day for the preceetling 2 years. There was no history of rheumatic fever, tuberculosis, recent or past history of chest pain or trauma, exposure to radiation, or recent upper respiratory infection.On examination, the blood pressure was 120/90 mmHg, with a regular pulse of 92/min, and a respiratory rate of 26/min. T h e neck veins were distentletl to the angle of the jaw at 90". T h e lung findings were consistent with the presence of bilateral pleural effusion. T h e apex pulsation was not palpable. T h e heart sounds were somewhat decreased, but audible; no third heart sound was heard. No murmurs or rubs were noted. Pulsus paradoxus of 15 mmHg was present and Kussmaul's sign was positive. Moderate ascites was demonstrated and the liver was palpable 7 cm below the right costal margin. Subcutaneous nodules were palpable on the left elbow and the right Achilles tendon. Typical rheumatoid deformities of the metacarpalphalangeal joints with flexion contractures of the right second and third fingers were noted. Shoulders, wrists, hips, knees, and ankles were normal. There was 3+ edema of the sacrum, thigh, and ankles. laboratory data. Hematocrit 38%; sedimentation rate 52 mm/hr (Westergren) ; lupus erythematosus preparations, negative; latex fixation, reactive"; protein bound iodine 6.8 mg%, serum cholesterol 155 me%. An intermediate PPD was negative..4 chest roentgenogram showed a cardiac to thoracic ratio of 15/28 and bilateral pleural eff usions. The electrocardiogram revealed low voltage QRS complexes and flattened T waves in all lrads. *Hyland Laboratories. 1.0s Aiigeles, Calif.