Answer:

Chest computed tomography scan

Discussion

The finding on echocardiography in this study was concerning for a pericardial cyst vs pericardial mass; thus, further imaging was necessary to further evaluate the structure. Although transesophageal echo might have improved the visualization of the structure, the best imaging modalities for evaluating the pericardium is computed tomography (CT) scan or magnetic resonance imaging (MRI).

A CT scan of the patient’s chest revealed large and loculated inflammatory pericardial effusion adjacent to the right ventricle. Although there appeared to be some extrinsic compression of the right ventricle, there was no early diastolic collapse and the patient showed no signs of hemodynamic compromise. The patient was completely asymptomatic.

After a multidisciplinary discussion that included the patient, the decision was made not to pursue pericardiocentesis but, rather, to allow the patient to continue with immunosuppressive therapy and follow up the effusion within a relatively short period of time with cardiac MRI.

The patient was instructed to come to the emergency room at the onset of any new symptoms, including chest pain, shortness of breath, palpitations, near syncope, or syncope at which point a pericardiocentesis would have been considered. Fortunately, he did well on tumor necrosis factor inhibitors and steroid therapy. His joint effusions and pain completely resolved. Follow-up MRI showed an improved pericardial effusion.

This case illustrates an unusual presentation of a common cardiac finding in patients with rheumatoid arthritis. Interventions should be tailored to the patient’s clinical symptoms and risk. 

Related Articles

follow @RheumAdvisor

Reference

Voskuyl AE. The heart and cardiovascular manifestations in rheumatoid arthritis. Rheumatology. 2006;45(Suppl4):iv4-7.

This article originally appeared on The Cardiology Advisor