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Papers of the Week

2022 Nov




Hemorrhagic Pericardial Effusion as the Presenting Symptom of Newly Diagnosed Rheumatoid Arthritis.


Basile EJ, Thompson I, Rafa O, Hanna ME, Sareen NJ
Cureus. 2022 Nov; 14(11):e31123.
PMID: 36479412.


Hemorrhagic pericardial effusion is a rare presenting sign of undiagnosed rheumatoid arthritis (RA). We present a case of a 58-year-old female with a history of mucinous cystadenoma with subsequent omental caking status-post small bowel resection, chronic intermittent bilateral knee pain, carpal tunnel syndrome of the left hand, and drainage of a peritoneal inclusion cyst two days prior to admission. The patient had pleuritic chest pain and acute-onset shortness of breath but was hemodynamically stable on presentation. Transthoracic echocardiogram and CT scan demonstrated a large pericardial effusion measuring 1.5 cm anteriorly, 2.21 cm posteriorly, and 2.5 cm laterally. Diagnostic pericardiocentesis revealed a hemorrhagic pericardial fluid with a glucose level of 133 mg/dL, pH of 7.34, albumin of 2.6 g/dL, red blood cell count of 401,000 cells per cubic millimeters (CUMM), white blood cell count of 1,400 CUMM, lactate dehydrogenase (LDH) of 930 U/L, and protein of 5 g/dL. Infectious and malignancy workups were negative. Rheumatologic workup was positive for elevated rheumatoid factor and anti-cyclic citrullinated peptide. The patient was diagnosed with RA; she was started on methotrexate with folic acid, and a pericardial drain was kept in place for three days. We present a brief review of the workup, etiologies, and therapeutic approach for patients who present with hemorrhagic pericardial effusion secondary to undiagnosed RA.