Successful etanercept treatment of constrictive pericarditis complicating rheumatoid arthritis (2022)

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Volume 44 Issue 12

December 2005

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E. Aslangul,

E. Aslangul

Correspondence to: S. Perrot, Service de Médecine Interne, Université Paris 5, René Descartes, Hotel Dieu, Place du Parvis Notre Dame, 75003 Paris, France. E-mail: serge.perrot@htd.aphp.fr

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S. Perrot,

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E. Durand,

E. Durand

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E. Mousseaux,

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C. Le Jeunne,

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L. Capron

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Rheumatology, Volume 44, Issue 12, December 2005, Pages 1581–1583, https://doi.org/10.1093/rheumatology/kei078

Published:

04 October 2005

Article history

Accepted:

14 July 2005

Published:

04 October 2005

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    E. Aslangul, S. Perrot, E. Durand, E. Mousseaux, C. Le Jeunne, L. Capron, Successful etanercept treatment of constrictive pericarditis complicating rheumatoid arthritis, Rheumatology, Volume 44, Issue 12, December 2005, Pages 1581–1583, https://doi.org/10.1093/rheumatology/kei078

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Sir, Effusive-constrictive pericarditis is a rare complication of pericarditis. Indeed, Sagrista-Sauleda et al. [1] observed only 15 cases in a prospective series of 1184 patients with pericarditis collected over 15 yr. After observing one case of rheumatoid arthritis with relapsing pericarditis eventually leading to severe pericardial constriction, despite intensive use of common disease-modifying drugs, we tested etanercept, an antagonist of tumour necrosis factor alpha (TNF-α), in a last attempt to avoid surgery.

A 36-yr-old woman was admitted to the cardiothoracic surgery department of our hospital in September 2003 because of pericarditis with cardiac tamponade. She had been treated for nodular and erosive rheumatoid arthritis for the past 5 yr with 10 mg/day prednisolone and 2 g/day salazopyrin. She also had chronic quiescent hepatitis C infection. She was not a drug addict and not a smoker. No other extra-articular involvement related to rheumatoid arthritis was found. Pericardial drainage yielded 1100 ml of fluid containing inflammatory cells (neutrophils and macrophages) but no bacteria, especially no mycobacteria after culture. The concentration of blood rheumatoid factor was 335 IU/ml (normally <15 IU/ml), ESR was 80 mm in the first hour and CRP was 70 mg/l. Rheumatoid pericarditis was diagnosed and immunosuppressive treatment was intensified: one intravenous bolus (250 mg) of methylprednisolone, followed by 10 mg/day prednisolone and 50 mg/day azathioprine. The patient rapidly improved and was discharged from hospital after 1 week.

Three months later, she presented again with pericarditis and tamponade. She underwent a second pericardiocentesis with drainage of 1050 ml. Treatment was strengthened with 100 mg/day azathioprine and 1 mg/kg/day prednisolone. This resulted in complete resolution of the pericardial effusion within 1 week. Prednisolone was rapidly tapered, but a third episode of pericardial effusion recurred 1 month later, when the dose had reached 15 mg/day. This time, she presented progressive right heart failure and was diagnosed with constrictive pericarditis, on the basis of echocardiography showing an 8 mm-thick posterior pericardium with moderate pericardial effusion. Doppler examination revealed a dip-plateau aspect of the pulmonary regurgitation flow. Cardiac magnetic resonance imaging (MRI) revealed inflammation of the pericardium with circumferential pericardial effusion, increased thickness and high signal intensity of both visceral and parietal layers of the pericardium due to enhancement 10 min after gadolinium injection (Fig. 1). We started anti-inflammatory therapy with three intravenous boluses (500 mg each) of methylprednisolone. No improvement was noted after 1 week. In an attempt to avoid surgical epicardiectomy, we decided to try antagonization of TNF-α with subcutaneous etanercept, 25 mg twice weekly. After 1 week, oedema and ascites had completely disappeared. Cardiac Doppler revealed that the dip-plateau aspect had resolved. Pericardial extravasation had decreased from 14 to 5 mm. The patient was discharged from hospital 10 days after the start of anti-TNF-α therapy. Six months later, no right ventricular signs or oedema have recurred. The MRI revealed that the pericardium was still abnormally thick, but it was now mobile throughout the cardiac cycle and did not enhance after contrast administration (Fig. 1).

Fig. 1.

Successful etanercept treatment of constrictive pericarditis complicating rheumatoid arthritis (3)

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Four chamber views of the heart in a cine gradient-echo technique (A and B) and small axis views in an inversion recovery gradient echo-technique 10 min after contrast administration (0.2 mmol/kg body weight Gd-DTPA) (C and D), before (A and C) and after three months of anti-TNF treatment (B and D).

Note the pericardial effusion (arrow in A and C), and the high signal intensity of both visceral and parietal layers of the pericardium due to the enhancement (open arrow head in C, before anti-TNF treatment), which are signs of acute inflammation. The increased thickness of the pericardium was still observed (filled arrow heads in B and D) after treatment but this pericardium was mobile using cine dysplay and not enhanced using the same inversion recovery gradient echo-technique after contrast administration.

Pericarditis occurs in 30–50% of rheumatoid arthritis patients, but only 1–3% were symptomatic in a set of patients assessed before 1990 [2]. Analysis of pericardial fluid commonly reveals inflammation with neutrophils [2]. Corticotherapy is usually curative but does not prevent recurrences or complications, and disease-modifying drugs are not efficient in rheumatoid pericarditis [2]. Complications of pericarditis, such as cardiac tamponade or constriction, are very rare in rheumatoid arthritis: 200 cases have been reported in the literature [3]. In rheumatoid pericardial constriction, steroids are totally inefficient and epicardiectomy is the only effective treatment described so far [3].

In our case, the first two episodes of pericarditis were complicated by cardiac tamponade. Surgical pericardial drainage preceded intensification of steroid therapy, which was successful on both occasions, with complete regression of clinical and echocardiographic abnormalities within 1 week. During the third episode within 4 months, constrictive pericarditis was diagnosed using echocardiography and Doppler, which showed signs typical enough to avoid cardiac catheterization [4]. Corticosteroid therapy, the aim of which was to reduce pericardial inflammation and effusion, was totally inefficient despite very high doses of methylprednisolone [5]. We decided to try anti-TNF-α therapy because the patient was quite reluctant to undergo a third surgical intervention and because anti-TNF therapy is the reference treatment for rheumatoid arthritis [6]. Dramatic clinical echocardiographic improvement followed rapidly: the dip-plateau disappeared within 1 week, and pericardial effusion completely resolved within 1 month. As pericardial inflammation involved the entire circumference, as shown by MRI, it is likely that the fibrosis was not yet fixed [7].

This report strongly suggests that anti-TNF-α therapy is effective in cases of constrictive pericarditis complicating rheumatoid arthritis, with established resistance to more conventional disease-modifying drugs. We conclude that etanercept therapy seems to be highly effective in inflammatory and constrictive pericarditis complicating rheumatoid arthritis, and should be considered as an alternative to surgery.

References

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Sagrista-Sauleda J, Angel J, Sanchez A et al. Effusive-constrictive pericarditis.

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Escalante A, Kaufman RL, Quismorio FP et al. Cardiac compression in rheumatoid pericarditis.

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(Video) Rheumatoid Arthritis: A New Era by Mathilde Pioro, MD

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Cohen A, Guyon P, Chauvel C et al. Relations between Doppler tracings of pulmonary regurgitation and invasive hemodynamics in acute right ventricular infarction complicating inferior wall left ventricular infarction.

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Weinblatt ME, Kremer JM, Bankhurst AD et al. A trial of etanercept, a recombinant tumor necrosis factor receptor:Fc fusion protein, in patients with rheumatoid arthritis receiving methotrexate.

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Klein C, Graf K, Fleck E et al. Acute fibrinous pericarditis assessed with magnetic resonance imaging.

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Author notes

Service de Médecine Interne, Hotel Dieu, 1Service de Cardiologie, 2Service de Radiologie vasculaire, and 3Service de Médecine Interne, Hopital Européen Georges Pompidou, Paris, France

© The Author 2005. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

© The Author 2005. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

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Polyarticular (similar to rheumatoid arthritis) involvement may be. seen very rarely in FMF patients (approximately 4% of the patients).. While a study. (5) has found that anti-CCP antibodies are not associated with FMF, two. other studies (6,7) have found that anti-CCP prevalence is higher in FMF. patients with arthritis than without arthritis.. Nevertheless, we continued colchicine treatment with etanercept,. because the coexistence of these two autoinflammatory disorders may. increase the risk of amyloidosis.. Etanercept may. be an effective treatment option in FMF and/or RA patients with. treatment-resistant arthritis.. Coexistence of familial. Mediterranean fever and rheumatoid arthritis in a case.

Muscular pain in the chest can mimic serious conditions like a heart attack or lung problems.. Arthritis chest pain has usually associated some exacerbation, such as minor trauma or upper respiratory infection, or it may be related to inflammation from the underlying arthritis condition.. High fever, sweating, or chills Breathing problems Signs of infection, including pus, swelling, and redness in the chest wall and rib joints Worsening pain despite taking medication Nausea. From what I have gathered from researching it online, most people report costochondritis feels like a heart attack, or pain in the heart, just as I felt it, though in fact, it is inflammation.. If you have rheumatoid arthritis, you may experience pain in your neck and chest as a result of your arthritis.. When chest pain occurs as a result of rheumatoid arthritis, it is called costochondritis, a condition that is often mistaken for a heart attack.. This pain is often a sharp, stabbing pain experienced in a small area near the center of your chest a heart attack usually radiates to other areas of your body and is often accompanied by lightheadedness and sweating.. Heart attack symptoms are extremely variable, but sometimes the pain in your chest extends to one or both shoulders and arms.. Costochondritis is not as common as inflammation in the joints of the hands, elbows, knees, or feet, but if you have inflammatory arthritis like rheumatoid arthritis, ankylosing spondylitis, or psoriatic arthritis, you may also be more likely to get costochondritis.. A common cause of shoulder pain is a tear of the rotator cuff, the muscles and tendons that hold the arm bone in place in the shoulder joint.. Shoulder pain can also be caused by diseases or conditions of the body outside the shoulder area, such as heart attack or gallbladder disease.. Unlike the pain of a heart attack, which radiates to other parts of the body and is often accompanied by symptoms such as nausea or light-headedness, the pain of costochondritis is localized to the center of the chest.. If you are experiencing symptoms of a possible heart attack, including pressure in your chest accompanied by pain in neck, jaw, shoulder or arms, call 911 or get to the emergency room immediately.. As if the chronic pain and mobility challenges of rheumatoid arthritis werent burdensome enough, its becoming clearer that people with the disease face another serious health threata greater risk for heart disease.. Some 1.5 million Americans, a majority of them women, have this form of arthritis, an autoimmune disease that happens when the immune system attacks the bodys own tissues, causing pain, swelling, stiffness and loss of function in the joints.

Regarding clinical management and therapy of acute pericarditis, it is not mandatory to search for the aetiology in all patients, especially in countries with a low prevalence of tuberculosis (TB) because of the relatively benign course associated with the common causes of pericarditis and the relatively low yield of diagnostic investigations [1].. Cardiac tamponade rarely occurs in patients with acute idiopathic pericarditis, and is more common in patients with a specific underlying aetiology, such as malignancy, TB or purulent pericarditis.. Recurrent pericarditis is diagnosed with a documented first episode of acute pericarditis, a symptom-free interval of four to six weeks or longer and evidence of subsequent recurrence of pericarditis.. Medical therapy of pericardial diseases: part II: noninfectious pericarditis, pericardial effusion and constrictive pericarditis .. Imazio M., Bobbio M., Cecchi E., Demarie D., Demichelis B., Pomari F., Moratti M., Gaschino G., Giammaria M., Ghisio A., Belli R., & Trinchero R. Colchicine in addition to conventional therapy for acute pericarditis: results of the COLchicine for acute PEricarditis (COPE) trial.

3 Bevans, M, et al, American_Journal of Medicine, 1954, 16, 197.. Rheumatoid constrictive pericarditis Often silent and symptomless and discovered only at necropsy, pericarditis is nevertheless common in rheumatoid arthritis.. In adults Hollingsworth2 quotes pericarditis as being found at necropsy in 30-50°O of cases of rheumatoid arthritis and comments that when it is clinically apparent pericarditis is usually a complication of the later stages of the disease-though in both children and adults it may occur early and may even herald the onset of the disease.. This has now changed, and today pyogenic arthritis and rheumatoid arthritis are more frequent causes.. Moreover, the course of the complication in the latter may be quick: one patient whose disease started in January 1962 had to have a pericardiectomy for constrictive pericarditis in July the next year.7 At operation the whole heart was found to be constricted with a fibrous covering 1-5 mm thick.. Surgical diathermy is still not foolproof In surgical operations the use of diathermy current for coagulating blood vessels and cutting through vascular tissue permits a high standard of haemostatic control not readily achieved by any other means.. The current oscillating between two electrodes in contact with the body heats all the tissues between them; hence the name diathermy (Greek dia: through, and therme: heat).. The use of diathermy currents in operating theatres carries certain dangers.

The 2015 European Society of Cardiology (ESC) update of their 2004 guidelines on the diagnosis and management of pericardial diseases recommends managing patients considered to be low risk (no risk factors) on an outpatient basis, whereas those with at least one risk factor should be managed as inpatients (both class I, level B evidence).. For acute pericarditis, the 2015 European Society of Cardiology (ESC) update of their 2004 guidelines on the diagnosis and management of pericardial diseases recommends the following (all class I, level A evidence) [ 3 , 4 ] :. Imazio et al found evidence that in patients with acute pericarditis, colchicine, when added to conventional anti-inflammatory therapy, significantly reduced the rate of incessant or recurrent pericarditis.. [ 47 ] In a trial of 240 adults with acute pericarditis randomly assigned to receive colchicine (n = 120) or placebo (n = 120) for 3 months in addition to conventional anti-inflammatory therapy with aspirin or ibuprofen, the primary study outcome of incessant or recurrent pericarditis occurred in 20 patients (16.7%) in the colchicine group and 45 patients (37.5%) in the placebo group.. Surgical procedures for pericarditis include pericardiectomy for constrictive pericarditis, as well as pericardiocentesis, pericardial window placement, or pericardiotomy to drain pericardial fluid.. This procedure is used for constrictive pericarditis, effusive pericarditis, or recurrent pericarditis with multiple attacks, steroid dependence, and/or intolerance to other medical management.. [ 49 ] The report involved 27 pediatric patients (mean age, 16.7 y), including 16 patients with inflammatory pericarditis and 11 with constrictive pericarditis.

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