Case Report: Rheumatoid Arthritis-Associated Restrictive Pericarditis

Following two infusions of 1,000 mg rituximab eight weeks apart, the patient’s symptoms resolved.
Supawit Srethbhakdi / shutterstock.com

Rheumatoid arthritis (RA) is a systemic autoimmune disease that affects approximately 1% of the adult population, and involvement of extra-articular tissue occurs in approximately 40% of patients over their lifetimes.¹ RA-associated pericardial disease is an uncommon complication, and surgery is the only definitive therapy—according to current literature.

In this report, we present the case of a 57-year-old man with rheumatoid factor and anti-CCP-positive RA who developed restrictive pericarditis that resolved with initiation of anti-CD20 therapy—offering a potentially novel and surgery-sparing therapy to treat a rare, highly mortal complication of RA.

The Case

A 57-year-old man presented to a general internal medicine clinic with shortness of breath and a cough that he’d had for about a month.

Four weeks prior to presentation, the patient developed worsening shortness of breath with exertion. The symptoms were stable and did not progress over the initial three weeks, but over the week prior to his presentation, he began to experience increased global fatigue with worsening dyspnea. He had an intermittent, non-productive cough. He denied a history of fever, chills, weight change, lightheadedness, exertional chest discomfort, palpitations, orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, cough, wheeze, focal weakness or myalgia.

Medical history: The patient’s medical history was significant for RA—he was diagnosed at age 53—complicated by interstitial lung disease (ILD), for which he was taking 20 mg of methotrexate weekly and 50 mg of etanercept weekly. He also has Graves’ disease, complicated by ophthalmopathy, for which he was taking 10 mg of methimazole daily. He suffers from depression and anxiety, for which he was taking 40 mg of citalopram daily, 150 mg of buproprion twice daily and 0.5 mg of lorazepam as needed.

(click for larger image) Table 1: Initial Lab Work

Physical examination: The patient’s physical examination was notable for inspiratory crackles at the left base posteriorly with an elevated jugular venous pressure but no evidence of pulsus paradoxus.

Laboratory tests & imaging: Results of his laboratory evaluation were notable for interval elevation of his previously normal C-reactive protein and sedimentation rate, as well as his pro-brain natriuretic peptide level (see Table 1).

A chest X-ray demonstrated interval enlargement of the cardiomediastinal silhouette, with increased bilateral hilar, and vascular markings concerning for pulmonary edema with small bilateral pleural effusions.

An electrocardiogram showed a normal sinus rhythm at a rate of 80 beats per minute with normal intervals and diffuse low voltage. An echocardiogram revealed a moderate, circumferential pericardial effusion with subtle right ventricular diastolic collapse and less than 50% respiratory change in the inferior vena cava, consistent with elevated right atrial pressures.