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Rheumatoid constrictive pericarditis treated by pericardiectomy report of a case and review of the literature.

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ARTHRITIS ROUNDS
Rheumatoid Constrictive Pericarditis, Treated
by Pericardiectomy
Report of a Case and Review of the Literature
Jo5eph P. Liss a n d W. Thompson Bachmann
A case of constrictive cholesterol pericarditis with successful pericardiectomy
in a patient with rheumatoid arthritis is presented. The relationship between
rheumatoid arthritis and constrictive pericarditis is discussed. Twenty-five cases
of rheumatoid constrictive pericarditis, including 4 with constrictive cholesterol
pericarditis undergoing pericardiectomy are reviewed. In these cases, steroid
therapy did not appear to be beneficial, and early pericardiectomy is recommended.
T h e association of constrictive pericarditis in a patient with rheumatoid arthritis
and the subsequent finding of cholesterol
pericarditis at the time of pericardiectomy
prompted a review of the literature and
this case report.
CASE REPORT
A 51-year-old white woman entered the hospital
on Dec 15, 1967, with a history of orthopnea,
recurrent paroxysmal nocturnal dyspnea, ascites,
cough, and peripheral edema of 2-3 weeks duration.
Rheumatoid arthritis involving the hands predominantly (Fig 1) had been present for 12 years,
and was satisfactorily controlled by 5 mg of prednisone every other day for the preceetling 2 years.
There was n o history of rheumatic fever, tuberculosis, recent or past history of chest pain or trauma,
exposure to radiation, or recent upper respiratory
infection.
On examination, the blood pressure was 120/90
From Saint Francis Hospital, Hartford, Conn.
JOSEPHP. Lrss, MD, FACP: Assistant Director of
Cardiac Laboratory, Saint Francis Hospital, 114
Woodland St, Hartford, Conn 06105. W. THOMPSON
BACHMANN, MD: Resident in Medicine, Saint Francis Hospital.
Reprint requests should he addressed to Dr. Liss.
Submitted for puhliration Oct 30, 1969; acceptrtl
July G, 1970.
mmHg, with a regular pulse of 92/min, and a
respiratory rate of 26/min. T h e neck veins were
distentletl to the angle of the jaw at 90". T h e lung
findings were consistent with the presence of
bilateral pleural effusion. T h e apex pulsation was
not palpable. T h e heart sounds were somewhat
decreased, but audible; no third heart sound was
heard. No murmurs or rubs were noted. Pulsus
paradoxus of 15 mmHg was present and Kussmaul's
sign was positive. Moderate ascites was demonstrated and the liver was palpable 7 cm below the right
costal margin. Subcutaneous nodules were palpable
on the left elbow and the right Achilles tendon.
Typical rheumatoid deformities of the metacarpalphalangeal joints with flexion contractures of the
right second and third fingers were noted. Shoulders, wrists, hips, knees, and ankles were normal.
There was 3+ edema of the sacrum, thigh, and
ankles.
laboratory data. Hematocrit 38%; sedimentation rate 52 m m / h r (Westergren) ; lupus erythematosus preparations, negative; latex fixation, reactive"; protein bound iodine 6.8 mg%, serum cholesterol 155 me%. An intermediate PPD was negative.
.4 chest roentgenogram showed a cardiac to
thoracic ratio of 15/28 and bilateral pleural
eff usions. T h e electrocardiogram revealed low voltage QRS complexes and flattened T waves in all
lrads.
*Hyland Laboratories. 1.0s Aiigeles, Calif.
Arthritis and Rheumatism, Vol. 13, No. 6 (November-December 1970)
869
Fig 1. Hand radiograms demonstrate typical rheumatoid changes.
Hospital course. Treatment consisted of salt
restriction, bed rest, digitalis, and diuretics.
Right heart catheterization was performed on
Dec 19, 1967. The mean right atrial pressure was 23
mmHg. The right ventricular pressure was 50/26
with an early diastolic dip and plateau. The
pulmonary capillary mean wedge pressure was 25
mmHg. T h e right atrial pressure curve demonstrated a sharp ‘x’ descent, a short ‘y’ descent, and no ‘y’
trough, data consistent with pericardial effusion.
Right atrial angiocardiography documented a
pericardial effusion (Fig 2). After 300 ml of
serosanguineous fluid were removed from the pericardium, the right atrial pressure fell to 16 mmHg
suggesting the possibility of constriction.
Bacteriologic studies (including mycobacteria) ,
fungal studies, cytology, and lupus preparations on
the pericardial fluid were negative; however, the
latex fixation was reactive.
The patient lost 20 lb with a concomitant
disappearance of ascites and pleural and pericardial
effusion; hwever, distention of the neck veins,
hepatomegaly, and mild peripheral edema persisted. Despite corticosteroid therapy, the pericardia1 effusion recurred. The patient improved and was
discharged 4 weeks later and was maintained on
870
digitalis and prednisone. She was observing dietary
salt restriction.
One month later, the patient was readmitted for
complaints of increasing fatigue, dyspnea, recurrent
ascites, and increasing peripheral edema.
A pericardiectomy was performed on Feb 27,
1968. Two hundred milliliters of opaque, greenish
fluid was found in the pericardial sac. The cholesterol content of this fluid was 356 mg%. T h e
visceral and parietal pericardium were thickened to
3 mm. During the dissection, a small branch of the
left anterior descending coronary artery was divided
inadvertently.
Microscopic examination of the pericardium revealed fibrosis, focal hyalinization, perivascular
infiltration of mononuclear cells and numerous
cholesterol clefts. Myocardial biopsy revealed lymphocytic and granulocytic infiltration of the
myocardium.
The patient was discharged 2 weeks later. Examination 1 year later revealed Grade III/VI mid-andlate systolic murmurs with midsystolic accentuation, thought to be due to dysfunction of the
anterolateral papillary muscle. The patient had no
cardiorespiratory complaints and continued maintenance doses of digitalis and corticosteroid.
Arthritis and Rheumatism, Vol. 13, No. 6 (November-December 1970)
RHEUMATOID CONSTRICTIVE PERfCARDlTlS
Fig 2. Selective right atrial angiogran demonstrating a large pericardial effusion measuring 1.5 cm from right atrial
border to pericardium.
DISCUSSION
T h e reported incidence of all types of
pericarditis associated with rheumatoid arthritis in autopsy studies ranges from 11
(1) to 50% (2). Kirk and Cosh (3), in
their review of eight major autopsy series
totalling 400 patients found the incidence
to be 30%. Of hospitalized adult patients
with rheumatoid arthritis, pericarditis is
diagnosed clinically in only 2% (4,5,)
whereas its incidence in the juvenile form
is 7% (6). T h e discrepancy between the
incidence found at autopsy and that found
clinically was felt, by Wilkinson (5), to be
“due to failure of recognition on the part
of both patients and physicians”-the
physician being interested in the patient’s
articular complaints, frequent use of analgesics, and background of chronic discomfort. T h e importance of repeated examinations is evidenced by the systematic search
for pericarditis among 100 consecutively
hospitalized patients with rheumatoid arthritis by Kirk and Cash (3). Pericarditis
was recognized clinically in 31 of their patients, the cardinal sign being a pericardial
friction rub.
Rheumatoid pericarditis is generally a
benign and self limiting (3) process. However, close observation during the acute
Arthritis and Rheumatism, Vol. 13, No. 6 (November-December 1970)
871
NO
NO
NO
NO
Y
NO
NO
NO
NO
NO
Y
NO
NO
NO
Y
NO
NO
NO
NO
NO
NO
Y
NO
NO
NO
Y
nr
nr
nr
nr
NO
Y
nr
nr
nr
Y
nr
nr
nr
Y
Y
nr
nr
nr
Y
Y
Y
Y
Y
Y
Y
Y
NO
NO
Y
Y
Y
NO
Y
Y
Y
T
Y
Y
Y
Y
Y
Y
Y
PPD
LE
+
+
-
-
nr
+
nr
+
+
+
+
+
+
+
+
+
+
+
+
+
-
RF
nr
Y
nr
nr
Y
NO
Y
nr
NO
nr
nr
NO
Y
nr
nr
nr
nr
nr
nr
nr
nr
nr
SC
Nodules
F
M
4
4
M
M
M
a
2
12
M
5
61
41
49
70
42
51
53
48
46
59
26
2
22
1
7
4
54
53
M
F
F
M
M
M
38
51
54
31
29
58
49
40
F
M
F
M
M
M
M
55
49
Age
F
M
Sex
M
4
M
MD
MD
MD
MD
MD
Pd
S
M
MD
M
S
S
MD
MD
3
32
14
5
Duration
of RA
(years)
12
6
2
16
2
MD
MD
S
MD
M
S
S
Severity
of RA
toid factor; LE, Lupus erythematosus; PPD = 10 TU or unspecified; and Y, Yes.
S,Severe; RA. Rheumatoid arthritis; M, Mild; MD, Moderate; nr, not reported: sc, subcutaneous, pd, post dating pericarditis; RF, Rheuma-
Y
Y
NO
Y
nr
Y
Y
Y
Y
Y
T
Y
Y
Y
Y
Y
NO
NO
Y
NO
NO
Y
Benefited
from
surgery Steroids
* No other information reported on these patients.
Kerr-Taylor
Kennedy
Kennedy
Kennedy
Tubbs
Tubbs
Tubbs
Healey
Keith
McMurray
Szatkowski
Harrold
Harrold
Lange
Kindred
Glyn
Litchfield
Nair
Nair
Nair
Nair
Arnold
G imlette*
Gimlette*
Girnlette'
Authors
Cholesterol Chest
pericarditis pain
Table 1. Clinical Data on Reported Cases of Rheumatoid Pericarditis Undergoing Pericardiectomy
RHEUMAT0ID CONSTRICTIVE PER1CARDIT IS
episode and diligent follow-up is required,
because the development of pericardial
effusion with tamponade and pericardial
constriction is insidious. Smythe (7) mentions 5 patients with rheumatoid arthritis
who died of heart failure and were found
to have unsuspected, but extensive pericardial fibrosis at autopsy. A review of the
literature has yielded 25 cases of constrictive pericarditis associated with rheumatoid arthritis requiring pericardiectomy
(9-23) (Table 1). I n these cases there was
no relationship between the duration of
rheumatoid arthritis and onset of constriction. I n 1 patient (20) clinical rheumatoid
arthritis with a positive latex fixation did
not appear until 8 months after pericardiectomy. Pericardial involvement did
not appear to be related to the severity of
the disease or to the presence of subcutaneous nodules. !Serologic tests for rheumatoid
factor were positive initially i n all but 4
cases, 2 of which converted from negative
to positive after pericarditis was diagnosed
initially and 2 with persistent negative
serologic tests had established joint disease
consistent with rheumatoid arthritis. All
cases with positive intradermal tuberculin
tests had negative smears and cultures o n
pericardial fluid or tissue and had n o clinical evidence of prior tuberculosis infection.
One case exhibited nonspecific granulomata in the pericardium (1). All other microscopic inspections revealed nonspecific
fibrosis. Pericardial calcification
was
demonstrated in only 1 patient by pathology (17) and none by radiology.
Cholesterol pericarditis as defined by
Brawley et al (24) has been reported previously in 9 patients with rheumatoid arthritis (10, 11, 14, 25-27); 4 of these patients
were subjected to pericardiectomy (10, 11,
14, 21). We concur with Kindred et al
(10) that the relationship between pericarditis and rheumatoid arthritis may be
inore than coincidental, as to date only a
total of 52 cases of cholesterol pericarditis
have been reported.
Although Wilkinson (5) found that
treatment with steroid was beneficial in
rheumatoid pericarditis, Kirk and Cosh
(3) reported no benefit. In 16 of the 26
cases reviewed, i n which steroids were administered, constriction was not prevented
and all required surgery. I n 8 additional
cases of constrictive pericarditis with rheumatoid arthritis that did not undergo pericardiectomy, (8,22,23, 28,29) 6 died, 3 of
them after showing improvement from 3
weeks to 2% years. T h e results of pericardiectomy are encouraging in this lifethreatening situation, 22 of 26 cases benefited from surgery.
T h e case reported here is typical in its
presentation and clinical course. On the
basis of the cases reviewed in this discussion, it would appear that steroids have
little long-term benefit in rheumatoid constrictive pericarditis, and that early pericardiectomy is the treatment of choice.
ACKNOWLEDGMENTS
We are indebted to Frank Sullo, photographer,
Jason Hyun, MD, pathologist, Marie Aschenbrenner, LPN, and Gail Kuzontkoski, for their assistance.
REFERENCES
1. Fingerman DL, Andrus FC: Visceral lesions associated with rheumatoid arthritis.
Ann Rheumat Dis 3:168-181, 1943
2. Young D, Schwedel JB: The heart in
rheumatoid arthritis. Amer Heart J 28:l23, 1944
3. Kirk J, Cosh J: The pericarditis of rheumatoid arthritis. Quart J Med 38:397-423’,
1969
4. Cathcart ES, Spodick DH: Rheumatoid
heart disease. New Eng J Med 266:959964, 1964
5. Wilkinson M: Rheumatoid pericarditis.
Brit Med J 21723-1726, 1962
Arthritis and Rheumatism, Vol. 13, No. 6 (November-December 1970)
a73
L l S & BACHMANN
6. Lietman PS. Bywaters EGL: Pericarditis
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
in juvenile rheumatoid arthritis. Pediatrics
52855-860, 1963
Smythe HA: Rheumatoid arthritis and
constrictive pericarditis. A patient benefited by pericardiectomy (Discussion: Lange
RK, Weiss TE, Ochsner JL). Arthritis
Rheum 8:403-417, 1965
Latham BA: Pericarditis associated with
rheumatoid arthritis. Ann Rheumat Dis
25:235-241, 1966
Gimlette TMD: Constrictive pericarditis.
Brit Heart J 219-16, 1959
Kindred LH, Heilbrunn A, Dunn M:
Cholesterol pericarditis associated with
rheumatoid arthritis. Treatment by pericardiectomy. Amer J Cardiol 23:464-468,
1969
Szatkowski J, Inoue T: Cholesterol pericarditis. Amer J Cardiol 12:730-735, 1963
Kerr-Taylor H: Pericarditis in a case of
rheumatoid arthritis. Arthritis Rheum 19:
94-98, 1963, p 10
Kennedy WPU, Partridge REH, Mathews
MB: Rheumatoid pericarditis with cardiac
failure treated with pericardiectomy. Brit
Heart J 28:602-608, 1966
Tubbs OS, Slade PRH, Turner-Warwick
M: Constrictive pericarditis in association
with rheumatoid arthritis. Thorax 19:555560, 1964
Healey FH, Mozen HE: Chronic cardiac
compression (constrictive pericarditis) and
rheumatoid arthritis; A case report. Ohio
State Med J 53:1146-1147, 1957
Keith T A 111: Chronic constrictive pericarditis in association with rheumatoid
disease. Circulation 25:477-483, 1962
McNIurray C, Cayer D, Cornatzer WE:
Chronic adhesive pericarditis due to the
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
rheumatic state associated with liver d a m
age, serous effusions, and pigmentation.
Gastroenterology 17294-305, 1951
Harrold BP: Non-tuberculous constrictive
pericarditis. Brit Med J 1:29&292. 1968
Lange RK, Weiss TE, Ochsner JL: Arthritis and constrictive pericarditis. A patient benefited by pericardiectomy. Arthritis Kheum 8:403-417, 1965
Glyn JH, Pratt-Johnson JH: Rheumatoid
pericarditis. Brit Med J 1262, 1963
Litchfield JW: Kheumatoid pericarditis.
Brit Med J 1:682-683, 1963
Arnold EF, Maurice P: Trois observations
de pericardite chronique 5 cristaux de cholesterol. Cardiologia 38:85, 1961
Nair DV: Constrictive pericarditis in rheumatoid arthritis. J Ass Physicians India
14:373-382, 1966
Brawley RK, Vasko JS, Morrow AG: Cholesterol pericarditis. Consideration of its
pathogenesis and treatment. Amer J Med
41~235-248,1966
Ropes MW, Scully RE: Rheumatoid arthritis with pulmonary symptoms. Caze
records of the Massachusetts General Hospital 269:313-319, 1963
Kagan A: Cholesterol pericarditis and
rheumatoid arthritis (correspondence). New
Eng J Med 270:1020, 1964
Roberts JT: T h e heart in connective tissue
disorders, Progress in Arthritis. Edited by
JH Talbot, LM Lockie. New York, Grune
& Stratton, Inc, 1958, pp 40G428
Lebowitz WB: T h e heart in rheumatoid
arthritis. Ann Intern Med 58:102-123, 1963
Rothbard S, Steinberg I: Angiocardiogaphy in diagnosis of rheumatoid pericardial
effusion. New York J Med 67578-586,
1967
Discussion
Gerald P . Rodnan, M D , Pittsburgh, Pa.: The
authors of this report are to be commended for
focusing attention on an uncommon yet extremely
important-indeed, potentially life-threateningfeature of rheumatoid arthritis, namely constrictive
pericarditis. Until recently, there has been a re874
markable discrepancy between the high frequency
with which chronic adherent or obliterative pericarditis has been reported at postmortem examination of patients with rheumatoid arthritis and the
relative rarity with which pericarditis is recognized
during life. The observations of Kirk and Cosh (1)
Arthritis and Rheumatism, Vol. 13, No. 6 (November-December 1970)
RHEUMATOID CONSTRICTIVE PERICARDITIS
suggest that this paradox, unlike those recounted
by their countrymen Gilbert and Sullivan (2), is
more apparent than real. Impressed by se\eral
striking examples of rheumatoid pericarditis, Kirk
and Cosh conducted a systematic and painstaking
search among 100 consecutively admitted patients
with rheumatoid arthritis (Royal National Hospital
for Rheumatic Diseases, Bath) , comparing them
with an equal number of control subjects without
known cardiac disorder who were matched for age
and sex. No fewer than 10 of the patients with RA
were found to have pericardial friction rubs in
contrast to a single case among the controls-a man
thought to have lupoid hepatitis. In 5 instances,
this rub was the sole finding in support of the
diagnosis of pericarditis. Three patients were clinically unwell at the time (fever and/or pleurisy) but
only 1 had chest pain with pericarditis, and this
was atypical. The classical electrocardiographic
changes were notably absent in this group. Judging
from these and 23 other personal cases, which they
described in nice detail, Kirk and Cosh concluded
that rheumatoid pericarditis is generally a benign
and often symptomless disorder in which the
cardinal sign is pericardial friction, and the electrocardiographic changes of pericarditis are uncommon. They stressed the importance of recognizing
this condition in view of the insidious development
of pericardial effusion (6 cases), tamponade (3
cases), or constiiction (1 case).
We would agree with Kirk and Cosh. that this
new information goes “some way to resolve the
discrepancy between the frequency of pericarditis as
an autopsy finding in rheumatoid arthritis (about
30 per cent) and its apparent rarity in life.” Their
report thus illustrates the general proposition that
“Man sieht was er weisst” (Goethe) and supports
Osler’s injunction that “Pericarditis is diagnosed in
proportion to the care [including frequency] of the
examination.” I t is not difficult to understand how
rheumatoid pericarditis can be overlooked, in view
of the fact that this condition is often asymptomatic
(? the result of treatment with salicylates, other
analgesics, and corticosteroids) . T h e questioning
and examination of the patient with RA too often
become so preoccupied with rheumatic complaints
that the significance of extra-articular manifestations is overlooked or otherwise misjudged-eg,
chest pain is ascribed to disease of the stemoclavicular or costo-chondral junctures. Furthermore, it is not unusual for patients to withhold
certain information in the mistaken belief that the
physicians in the rheumatology clinic are “only
interested in their joints.”
We are prepared then to accept the idea that
pericarditis is far more common in patients with
RA than recognized heretofore. What evidence is
there that this pericarditis is rheumatoid in nature?
In most cases we are dealing with “guilt by
atsociation,” and in practice it is often difficult to
determine whether the pericarditis encountered i n
the patient with RA is not due to some other
cause. As noted by Drs. Liss and Bachmann, pathologic scrutiny of pericardial tissue usually reveals
nonspecific fibrosis, and only rarely does one encounter convincing rheumatoid
granulomata.
Greater emphasis should be placed on examining
the pericardial effusion fluid. The low glucose
content and high rheumatoid factor concentration
of this liquid is well recognized. In a recent case, we
observed that the polymorphonuclear leukocytes
present in the pericardial effusion contained numerous cytoplasmic inclusions, many of which are identified as consisting, in part, of immunoglobulin M.
This, together with the finding of diminished complement level, suggests that conditions inside this
patient’s pericardial sac were similar to those inside
her joints, and that pericarditis was the result of a
reaction based upon the formation of IgG-IgM and
other complexes followed by activation of complement, phagocytosis by neutrophilic leukocytes, and
the resultant consequences thereof. Clearly it would
be of great interest to have more information
concerning the levels of complement and lysosomal
enzymes in the pericardial fluid of these cases.
In this connection, mention should be made of
several reports describing RA cells, extremely low
glucose concentrations, and elevated lactic acid
clehydrogenase levels in the fluid of rheumatoid
pleural effusions (3-6). One of the patients observed by Berger and Seckler (4) developed peticarditis, and RA cells were found in the serosanguineous pericardial fluid, the glucose concentration
of which was less than 2 mg/100 ml.
Turning now to the problem of constrictive
disease, it appears that a number of cases labeled as
rheumatoid constrictive perioarditis may in reality
have been instances of effusion with tamponade. In
many reports it is not clear whether the cardiac
embarrassment is the result of (a) thickened
unyielding pcricardium (b) compression from accumulated exudate or (c) thickened visceral pericardium and epicardial peel. Although failure of
the right atrial pressure to return to normal levelf
after the pericardial fluid was removed in the
patient decribed by Drs. Liss and Bachmann does
indeed suggest an element of constriction, proof of
this rests with the observation of increased heart
Arthritis and Rheumatism, Vol. 13, No. 6 (November-December 1970)
875
11% & BACHMANN
size and filling after removal of the thickened
visceral pericardium coupled with postoperative
cardiac catheterization.
As noted by the authors, chronic pericardial
effusions occurring in patients with rheumatoid
arthritis often contain a high concen’tration of
cholesterol, and the inordinately frequent association of this so-called cholesterol pericarditis with
rheumatoid arthritis suggests a more than coincidental relationship. It is of interest to note that
rheumatoid pleural effusions, too, (as well as joint
effusions) are often cholesterol-laden (6, 7). Although cholesterol pericarddtis has been recognized
for a half-century, the pathogenesis of this condition remains unclear. Considered, at first, an unusual and specific form of pericarditis, it is now known
that pericardial effusions that contain large
amounts of cholesterol may be found after pericarditis of any cause as well as in severe hypothyroidism (8,9). Cholesterol pericarditis in a euthyroid patient appears to be the result of a chronic
pericardial inflammation that thickens the membrane thereby impairing its ability to absorb the
lipid contained in the pericardial fluid. Gradual
concentration of the cholesterol eventually leads to
its precipitation as crystals and intrapericardial
deposits.
REFERENCES
1. Kirk J, Cosh J: T h e pericarditis of rheumatoid arthritis. Quart J Med 38397-423,
I969
2. Gilbert WS, Sullivan AS: The Pirates of
Penzance, Act 2.
3. Carmichael DS, Golding DN: Rheumatoid
pleural effusions with “RA cells” in the
pleural fluid. Brit Med J 2314, 1967
4. Berger HW, Seckler SG: Pleural and pericardial effusions in rheumatoid disease.
Ann Intern Med 64:1291-1297, 1966
5 . Mandl MAJ, Watson JI, Henderson JAM,
e t al: Pleural fluid in rheumatoid arthritis.
Arch Intern Med (Chicago) 124373-376,
1969
876
6. Stengel BF, Watson RR, Darling RJ: Pulmonary rheumatoid nodule with cavitation
and chronic lipid effusion. JAMA 198:
1263-1266, 1966
7. Dodson W H , Hollingsworth JW: Pleural
effusion in rheumatoid arthritis. New Eng
J Med 275:1337-1342, 1966
8. Brawley RK, Vasko JS, Morrow AG: Cholesterol pericarditis. Considerations of its
pathogenesis and treatment. Amer J Med
413235-248, 1966
9. Doherty JE, Jenkins BJ, Gammill J, et al:
Radiocarbon cholesterol turnover in cholesterol pericarditis. Amer J Med 41:322330, 1966
AUTHORS’ COMMENTS
Doctor Bachmann and I wish to thank
Dr. Rodnan for his interesting and critical
review. We must agree that we are dealing
with “guilt by association” and that the
finding of a low glucose content and high
rheumatoid factor concentration i n the
pericardial fluid would have made the association a stronger one.
Review of the surgical note on our patient revealed that the visceral and parietal
pericardium were both thickened to 2-5
mm and that the visceral pericardium “was
limiting cardiac action.”
Since submission of this article for publication 2 more reported cases of rheumatoid
arthritis complicated by constrictive pericarditis and treated successfully by pericardiectomy have been published.
(Batley WJ et al: Rheumatoid arthritis
complicated by constrictive pericarditis:
Report of a case treated successfully by
pericardiectomy. Canad Med Ass J 100:
863-866, JOSEPH P. LISS, MD and
W. THOMPSON
BACHMANN,
MD.
Arthritis and Rheumatism, Vol. 13, No. 6 (November-December 1970)
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