Abstract 19722: Pericardial Mass in a Patient With Rheumatoid Arthritis: A Case Report
Introduction: Rheumatoid arthritis (RA) can affect the heart via either inflammatory or ischemic processes. Pericardial disease is common in RA patients (30-50%) but is usually subclinical and not hemodynamically significant unless accompanied by infiltrative cardiomyopathy which carries a poor prognosis.
Case report: A 65 year-old Caucasian male presented with long standing RA, severe fatigue and mild arthritis of MCP joints. Physical examination indicated S3, II/VI decrescendo diastolic murmur, and 2+ LL edema. ESR was normal but anti-CCP antibodies were > 250 units. On echocardiogram, a large pericardial mass was detected without atrial nor ventricular collapse and mild-moderate aortic regurgitation. Cardiac MRI defined the mass as a heterogeneous entity attached to the right, anterior, and inferior borders of the heart with compression of the right atrium, left and right ventricles, and the tricuspid valve. CT guided biopsy demonstrated fibrinous material without granulomas nor infection. Fatigue was initially attributed to uncontrolled RA and low dose prednisone and Leflunamide were started. 3 months later, he developed frank heart failure with NYHA class IIIb functional impairment. Cardiac Tamponade was confirmed by heart catheterization demonstrating typical 4-chamber pressure equalization. The mass was surgically excised with partial pericardiectomy. The patient had a dramatic improvement and 4 years later, he remains asymptomatic.
Discussion: Our patient presented with uncontrolled RA and a pericardial mass that was not hemodynamically significant per the initial echocardiogram. Despite intensifying immunosuppression, his fatigue progressed with signs of congestive heart failure. Tamponade physiology was diagnosed invasively and the mass was resected with excellent recovery. Microscopically, the lesion consisted of a fibrous and exudative material. The patient likely had multiple asymptomatic episodes of pericarditis, gradually leading to this condition. We demonstrate with this case that RA pericardial disease can cause hemodynamic compromise while sparing myocardium and valves and that surgery is associated with very good prognosis. Physicians should be vigilant about a cardiac cause of fatigue in RA patients.
Author Disclosures: M.A. Al-Ani: None. M.H. Weber: None. A.R. Lucas: None. M.D. Kosboth: None.
- © 2014 by American Heart Association, Inc.