Rheumatoid arthritis and pericardial effusion – a unique major manifestation
  • Isabel Cruz
    Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
  • Bruno Bragança
    Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
  • Rafaela Lopes
    Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
  • Rui Santos
    Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
  • Aurora Andrade
    Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal


Pericardial effusion, rheumatoid arthritis, pleuropericardial window


Introduction: Pericardial effusion is common in the setting of rheumatoid arthritis (RA); however, it is rarely its first manifestation.
Case description: An 82-year-old male presented with abdominal pain, vomiting and fever. Blood analysis revealed elevated systemic inflammatory markers, and an abdominal computed tomography scan revealed non-specific alveolar condensation of the right pulmonary base and pericardial effusion subsequently quantified as medium size by transthoracic echocardiography. A large aetiological panel was requested, with the autoimmunity study revealing high levels of rheumatoid factor (RF) and anti-citrullinated cyclic peptide (anti-CCP) antibodies. Since the patient did not present articular involvement, the initial hypothesis was pericardial effusion due to pneumonia and no specific treatment for RA was started. At follow-up, the pericardial effusion recurred and a pericardiocentesis was performed. The pericardial fluid analysis was sterile, and no malignant cells were identified. A new serological study confirmed high levels of RF and anti-CCP antibodies, and immunomodulatory treatment was initiated. After one year, the pericardial effusion recurred due to non-compliance with immunomodulatory therapy. A surgical pleuro-pericardial window was performed, and the cytological study of the pericardial patch revealed submesothelial thickening and foci of perivascular lymphocytic infiltrate. The patient remained asymptomatic.
Discussion: After exclusion of a large spectrum of infectious and non-infectious causes and the relapse after suspension of immunomodulatory treatment, the most probable aetiology for the pericardial effusion remains RA.
Conclusion: Pericardial syndromes can be the first manifestation of AR even in the absence of articular symptoms and this disease must be considered in the aetiological investigation.



  • Imazio M. Pericardial involvement in systemic autoimmune diseases [Internet]. 2022. Available from: https://www.uptodate.com/contents/pericardial-involvement-in-systemic-autoimmune-diseases
  • Davis JM. Overview of the systemic and nonarticular manifestations of rheumatoid arthritis [Internet]. UpToDate. 2018. Available from: https://www.uptodate.com/contents/overview-of-the-systemic-and-nonarticular-manifestations-of-rheumatoid-arthritis
  • Owlia MB, Mostafavi Pour Manshadi SM, Naderi N. Cardiac manifestations of rheumatological conditions: a narrative review. ISRN Rheumatol 2012;2012:463620.
  • Whitfield N, Krasniak A, Nguyen H. Concomitant large loculated pleural and pericardial effusions in a patient with rheumatoid arthritis on methotrexate. Perm J 2020;24:1.
  • Taylor PC. Update on the diagnosis and management of early rheumatoid arthritis. Clin Med (Lond) 2020;20:561–564.
  • Alivernini S, Tolusso B, Petricca L, Ferraccioli G, Gremese E. Rheumatoid arthritis. In: Perricone C, Shoenfeld Y, editors. The mosaic of autoimmunity: the novel factors of autoimmune diseases, Amsterdam: Elsevier; 2019, p. 501–526.
  • Guo Q, Wang Y, Xu D, Nossent J, Pavlos NJ, Xu J. Rheumatoid arthritis: pathological mechanisms and modern pharmacologic therapies. Bone Res 2018;6:15.
  • Cojocaru M, Cojocaru IM, Silosi I, Vrabie CD, Tanasescu R. Extra-articular manifestations in rheumatoid arthritis. Maedica (Buchar) 2010;5:286–291.
  • Van Hoovels L, Studenic P, Sieghart D, Steiner G, Bossuyt X, Rönnelid J. Impact of autoimmune serology test results on RA classification and diagnosis. J Transl Autoimmun 2022;5:2022.
  • Taylor PC, Deleuran B. Biologic markers in the diagnosis and assessment of rheumatoid arthritis [Internet]. 2023. Available from: https://www.uptodate.com/contents/biologic-markers-in-the-diagnosis-and-assessment-of-rheumatoid-arthritis
  • Smolen JS, Aletaha D, Barton A, Burmester GR, Emery P, Firestein GS, et al. Rheumatoid arthritis. Nat Rev Dis Primers 2018;4:18001.
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    Published: 2024-01-09
    Issue: 2024: Vol 11 No 2 (view)

    How to cite:
    Cruz I, Bragança B, Lopes R, Santos R, Andrade A. Rheumatoid arthritis and pericardial effusion – a unique major manifestation. EJCRIM 2024;11 doi:10.12890/2024_004159.

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