An Unusual Cause of Dyspnea in a Patient with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic systemic inflammatory condition of unknown etiology that affects the joints and the visceral serosa of heart, lungs and peritoneum. Pericarditis and pericardial effusion are the most common presentations of cardiac involvement. Pericardial tamponade is extremely rare affecting <1% of these patients. We report an interesting case of a young female with poorly controlled RA who presented with progressive dyspnea. Initial work-up was concerning for pericardial effusion based on chest radiographic and electrocardiographic findings. A transthoracic echocardiogram confirmed a large pericardial effusion. Elevated inflammatory markers and serological evidence of an active disease were detected on blood tests. A repeat echocardiogram performed to evaluate worsening of dyspnea and hypotension revealed increase in pericardial effusion. A right heart catheterization revealed equalization of diastolic pressures in the right atrium, right ventricle, and pulmonary artery wedge pressure diagnostic of pericardial tamponade. An emergent pericardiocentesis was performed to relieve the pericardial pressure. She was treated with steroids to prevent reaccumulation of the pericardial fluid. An echocardiogram at follow-up visit 4 weeks later showed stable small pericardial effusion. Our case underscores the significance of early detection and treatment of a rare but potentially life-threatening complication such as cardiac tamponade to prevent bad outcome.