CLINICAL SPOTLIGHT Clinical Spotlight A Clinico-pathological Conference on Constrictive Pericarditis Secondary to Rheumatoid Arthritis: A Case Report with Expert Commentary and Review of the Literature Adam D. Jordan, MBBS, BSc a,∗ , Muhammad E.A. Khan, MBBS, MRCSEd a , Edward T. Hoey, MB BCh, BAO, MRCP, FRCS b , Doris Rassl, MBBS, FRCPath c and Samer A.M. Nashef, MBChB, PhD, FRCS a a Department of Cardiothoracic Surgery, Papworth Hospital, Ermine Street North, Cambridge CB23 3RE, UK b Department of Radiology, Papworth Hospital, Cambridge, UK c Department of Pathology, Papworth Hospital, Cambridge, UK Constrictive pericarditis is the commonest cardiac complication of rheumatoid arthritis (RA). Two percent of patients with RA develop significant clinical symptoms of pericarditis, which may not correlate with joint disease duration or severity. Symptoms are often vague and non-specific, which frequently delays the diagnosis and subsequent management. Surgical excision of the pericardium is the only definitive treatment option. We present the case of a 60 year-old lady with RA who presented with symptoms due to pericardial constriction and underwent radical pericardectomy. (Heart, Lung and Circulation 2011;20:24–29) © 2010 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. Keywords. Constrictive pericarditis; Rheumatoid arthritis; Pericardectomy Introduction R heumatoid arthritis (RA) is a chronic, systemic, autoimmune disease that predominantly involves synovial tissue but can be associated with a variety of extra-articular manifestations. Cardiac involvement is well recognised and can include coronary arteritis, left ventricular systolic and diastolic dysfunction, mitral regur- gitation and fibrinous pericarditis [1]. Pericarditis is rarely of clinical significance but in a small proportion of patients it can progress and become constrictive. We present a case of constrictive pericarditis in a patient with severe but con- trolled rheumatoid arthritis, who was successfully treated by radical pericardiectomy. Clinical Presentation A 60 year-old lady presented with increasing shortness of breath, peripheral oedema, anterior chest discomfort and night cough. She had no orthopnoea, paroxysmal noctur- nal dyspnoea or syncope. Functional classification of her symptoms were NYHA II and CCS 1. Her past medical Received 25 April 2010; received in revised form 22 July 2010; accepted 17 August 2010; available online 18 September 2010 ∗ Corresponding author. Tel.: +44 01223 245151. E-mail address: adamdjordan@doctors.org.uk (A.D. Jordan). history included severe rheumatoid arthritis, for which she had been taking prednisolone for 11 years. Although her joint symptoms were well controlled at time of pre- sentation, previous exacerbations had left her functionally wheelchair-bound. There was no other significant medi- cal history. There was a family history of ischaemic heart disease and she was an ex-smoker. On examination she appeared well and comfortable at rest. Her pulse was regular at 98 beats per minute, and blood pressure was 160/90. Heart sounds were normal, with no murmurs and no pericardial rub. Her chest was resonant to percussion and clear on auscultation. Jugular venous pressure was elevated and there was moderate, bilateral, pitting leg oedema. Commentary (Mr Samer Nashef, consultant cardiotho- racic surgeon): “The initial diagnosis was of congestive cardiac failure (CCF), with clinical signs suggesting both left and right heart dysfunction. The most likely causes of CCF in this patient were undiagnosed ischaemic heart disease and chronic uncon- trolled hypertension. Heart valve disease, while not clinically apparent, was also considered. Cardiomyopathy and undi- agnosed congenital heart disease were unlikely but possible diagnoses. The history of rheumatoid arthritis was deemed to be important, and while clinical manifestations of rheumatoid heart disease are rare, post-mortem studies show many patients with rheumatoid arthritis have sub-clinical cardiac manifesta- tions. These include pericarditis (effusive or constrictive), mitral © 2010 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved. 1443-9506/04/$36.00 doi:10.1016/j.hlc.2010.08.014