A case of effusive-constrictive pericarditis accompanying rheumatoid arthritis: The possibility of adverse effect of TNF-inhibitor therapy

Evaluation and Management of Pericarditis in Rheumatic Diseases

ABSTRACT

This review summarizes the evaluation for underlying rheumatic conditions in patients presenting with acute pericarditis, treatment considerations for specific rheumatic conditions, and the role of imaging in diagnosis and monitoring. Pericarditis may be one of the initial presentations of a rheumatic disease or identified in a patient with known rheumatic disease. There is also growing evidence for using anti-inflammatory and immunosuppressive agents for treating recurrent pericarditis, which can overlap with the treatment of rheumatic diseases.

Calcific constrictive pericarditis following tumour necrosis factor-alpha inhibition

Background

Tumour necrosis factor (TNF)-alpha inhibition is a core therapeutic avenue for a broad range of inflammatory and autoimmune disorders including rheumatoid arthritis and inflammatory bowel disease, as well as dermatological conditions such as hidradenitis suppurativa. Adalimumab has become one of the most common TNF-alpha-inhibiting agents, which is used for many of these conditions. Treatment with such agents is associated with numerous systemic side effects, though cardiac complications remain relatively rare. These include reports of pericarditis and pericardial effusions1-3.

Case summary

A 63-year-old lady was referred to the outpatient respiratory clinic with a 1-year history of increasing breathlessness, on a background of 4 years of treatment with adalimumab for Stage III hidradenitis suppurativa. A high-resolution computed tomography (CT) thorax revealed evidence of pericardial calcification. Subsequent left and right heart catheterization study revealed equalization of intraventricular pressures, consistent with constrictive pericarditis. A QuantiFERON test was negative, and rheumatological serology was unremarkable. The patient was initially managed conservatively with close follow-up, before undergoing surgical pericardectomy when she developed signs of cardiac failure.

Discussion

Adalimumab is associated with a range of systemic side effects, though cardiac complications are relatively rare. This case highlights a potentially novel complication associated with prolonged adalimumab therapy. Given that there are reports in the literature of pericarditis and pericardial effusions associated with TNF-alpha inhibition1-3, it is reasonable to hypothesize that the calcific constrictive pericarditis seen in this case may demonstrate a novel cardiac phenomenon associated with this therapy, given the lack of any traditional aetiological factors.

Hemorrhagic pericardial effusion following treatment with infliximab: A case report and literature review

BACKGROUND

Infliximab (IFX) is an anti-tumor necrosis factor alpha (TNF-α) agent that is widely used for the management of a variety of autoimmune and inflammatory diseases, including Crohn's disease (CD). As a result of its increasing administration, new complications have emerged. Hemorrhagic pericardial effusion, secondary to IFX therapy, is a rare but life-threatening complication.

CASE SUMMARY

A 27-year-old man was diagnosed with CD (Montreal A2L3B1) 6 years prior. After failing to respond to mesalazine and methylprednisolone, he took the first dose of IFX 300 mg based on his weight (60 kg, dose 5 mg/kg) on December 3, 2018. He responded well to this therapy. However, on January 21, 2019, 1 wk after the third injection, he suddenly developed dyspnea, fever, and worsening weakness and was admitted to our hospital. On admission, computed tomography scan of the chest revealed a large pericardial effusion and a small right-side pleural effusion. An echocardiogram showed a large pericardial effusion and normal left ventricular function. Then successful ultrasound-guided pericardiocentesis was performed and 600 mL hemorrhagic fluid was drained. There was no evidence of infection and the concentrations of TNF-α, IFX, and anti-IFX antibody were 7.09 pg/mL (reference range < 8.1 pg/mL), < 0.4 μg/mL (> 1.0 μg/mL), and 373 ng/mL (< 30 ng/mL), respectively. As the IFX instruction manual for injection does mention pericardial effusion as a rare adverse reaction (≥ 1/10000, < 1/1000), so we discontinued the IFX. Monitoring of the patient’s echocardiogram for 2 mo without IFX therapy showed no recurrence of hemorrhagic pericardial effusion. Follow-up visits and examinations every 3 to 6 mo until April 2021 showed no recurrence of CD or pericardial effusion.

CONCLUSION

This is a case of hemorrhagic pericardial effusion following treatment with IFX. It is a rare but life-threatening complication of IFX. Early recognition helps prevent the occurrence of hemorrhagic pericardial effusion and minimize the impact on the natural evolution of the disease.

Pericardial Manifestations in Inflammatory Bowel Disease: A Report of Two Cases

Pericardial involvement in the setting of inflammatory bowel disease can occur not only as an adverse event related to medical therapy but also as an extraintestinal manifestation of the disease itself. In the following case series, we describe 2 cases of pericarditis in patients diagnosed with Crohn disease. Our first case reviews the clinical presentation of acute pericarditis as an adverse event associated with anti-tumor necrosis factor therapy. In contrast, our second patient is a case of acute pericarditis as a precursor of the clinical recurrence of Crohn disease following operative resection. Pericardial disease should be considered in the differential diagnosis of acute and subacute presentations of chest discomfort and shortness of breath in patients with inflammatory bowel disease.