5-ASA Induced Recurrent Myopericarditis and Cardiac Tamponade in a Patient with Ulcerative Colitis

A 20-year-old woman with recently diagnosed moderate left-sided ulcerative colitis (UC) presented to the emergency department (ED) for chest pain. Two months earlier, she had been evaluated in gastroenterology clinic for bloody diarrhea and crampy left lower quadrant abdominal pain. Stool tests for infectious causes were negative. Colonoscopy demonstrated diffuse mucosal erythema, linear ulcerations, and friability that extended continuously from the rectum to the descending colon (Fig. 1), histologically reported as acute and chronic colitis with crypt architectural distortion, consistent with inflammatory bowel disease. No granulomas or viral inclusion bodies were seen. Institution of sulfasalazine 500 mg four times daily and mesalamine enemas significantly improved her symptoms. Three weeks later, she presented to the ED with pleuritic chest pain, aggravated by lying flat and relieved by leaning forward. She denied nausea, vomiting, coryza, or cough. She was afebrile, with a heart rate 116 beats per minute and blood pressure 102/67 mmHg. Physical exam was notable for a friction rub heard loudest over the left sternal border, mild epigastric tenderness, and 1? pitting edema to the mid-shin. Laboratory examination revealed leukocytosis with neutrophilia (WBC 16.8 k/ll, 82.8 % neutrophils), elevated troponin, creatine kinase-myocardial band (CK-MB), erythrocyte sedimentation rate (ESR), and C-reactive protein. ECG revealed diffuse ST elevation. Echocardiography revealed a small pericardial effusion with normal systolic function (Fig. 2), which was also noted in the CT angiogram report, with no evidence of pulmonary embolism or other chest pathology. The patient was diagnosed with acute myopericarditis. Direct fluorescent antibody test for respiratory viruses, blood cultures, HIV antibody screen, PPD, and autoantibodies (including anti-nuclear antibody, anti-double-stranded DNA, and others) were all negative. Although viral myopericarditis could not definitively be excluded (since not all implicated viruses can be tested for), the main concern was for a reaction to sulfasalazine or, less likely, rectal mesalamine. Sulfasalazine was thus discontinued, mesalamine enemas were switched to hydrocortisone enemas, and she was treated with ibuprofen and colchicine, with symptom resolution. Low-dose balsalazide was then cautiously initiated. Five days later, the patient returned with recurrent severe pleuritic chest pain. She was hypotensive (85/52 mmHg) and tachycardic (117 bpm). Her ECG showed diffuse T wave flattening without electrical alternans. Bedside echocardiogram revealed a large pericardial effusion with hemodynamic compromise consistent with cardiac tamponade (Fig. 2). She underwent emergent pericardiocentesis with drainage of 300 ml of serosanguinous fluid. Fluid analysis and cultures were unrevealing. She was again treated with ibuprofen and colchicine, with discontinuation of the balsalazide, accompanied by marked improvement of her chest pain. Hydrocortisone enemas were prescribed with a plan for immunomodulator I. Sonu R. Wong M. E. Rothenberg Department of Medicine, Stanford University Medical Center, Stanford, CA, USA