Pericarditis Associated with Rheumatoid Arthritis
Authors: B. A. Latham
Journal: Annals of the Rheumatic Diseases (1966)

Evidence of old or recent pericarditis is a frequent autopsy finding in rheumatoid arthritis.The histo- logical appearances are generally non-specific, but the incidence is so high that an aetiological relation- ship must be assumed.Sokoloff (1953) reviewed the autopsy findings in 101 cases of rheumatoid arthritis (including seventeen which probably had ankylosing spondylitis by present criteria), and found that 40 6 per cent.showed evidence of pericarditis, compared with 8 8 per cent. of 1,154 consecutive unselected autopsies.Egelius, Gohle, Jonsson, and Wahlgren (1955) found evidence of pericarditis in seven out of thirteen autopsies in rheumatoid arthritis; they also reviewed the literature and found that 93 out of 288 reported autopsies of cases of rheumatoid arthritis showed evidence of pericarditis, an incidence of 32 * 3 per cent.Clinical reports of pericarditis associated with rheumatoid arthritis are still remarkably few.The purpose of this paper is to present three further cases, each associated with effusion, all of which came to autopsy. Case ReportsCase 1, a 60-year-old man, was admitted to hospital on August 19, 1964, with one week's history of acute pericarditis for which tetracycline had been prescribed.Rheumatoid arthritis had been present for 13 years.Examination.-He was slightly dyspnoeic with a pyrexia of 1010 F., pulse 100 per min., blood-pressure 110/80, jugular venous pressure raised 1 in., heart- sounds diminished.Advanced rheumatoid changes were present with subcutaneous nodules over both fore- arms, "swan's neck" deformity of the fingers, and swelling and deformity of the elbows, wrists, and knees.None of the joints was actively inflamed.Laboratory Investigations.-Haemoglobin11-3 g. per cent.; white blood count 37,000 per c. mm. with 88 per cent.neutrophils; erythrocyte sedimentation-rate 3 mm.per hr (Westergren); chest x ray-slight enlargement of cardiac shadow.Progress.-It was agreed that the pericarditis was probably infective and tetracycline was continued.One week later cardiac tamponade developed necessitating pericardial aspiration which yielded 85 ml.turbid, yellow fluid and gave immediate relief.The fluid contained numerous pus cells; protein 4 -0 g. per cent.; sugar 15 mg.per cent.; culture sterile.The clinical impression was still that he had an infective pericarditis which had been partially suppressed by chemotherapy, ampicillin ("Penbritin") was therefore given in place of tetracycline.Three further aspirations were required over the next week.He then improved temporarily but after another week the pericardial effusion re-accumulated with alarming rapidity (Figs 1 and 2, overleaf) and tamponade developed again.Aspiration yielded 300 ml.turbid, brown fluid with similar laboratory findings.At this stage it was strongly suspected that the peri- carditis might be rheumatoid in origin and he was given prednisone 60 mg.per day together with erythromycin and chloramphenicol as the possibility of infection still could not be discounted entirely.This was followed by dramatic improvement and over the next 2 weeks the prednisone was reduced steadily to 7 5 mg.per day.The patient then relapsed and developed a left pleural effusion in addition to recurrence of pericardial effusion.Pleural aspiration yielded 40 ml.yellow, opalescent fluid showing 5 to 10 pus cells per high-power field; protein 2* 8 g. per cent.; sugar 10 mg. per cent.; culture sterile.A firm diagnosis was then made of rheumatoid pericarditis.Prednisone was restored to 60 mg.per day and antibiotics were withdrawn.A generalized, red macular rash appeared for a few days at this time.