Steroid Dependent Pericarditis: Newer Treatment Options for Recurrent Pericarditis

A 36-year-old woman with past medical history of pericarditis, asthma, pulmonary embolism, hypothyroidism and iron deficiency anemia due to menorrhagia presents to clinic for a follow up visit with complaints of recurrent chest pain on deep breathing. Chest pain is worse on lying down and improved when leaning forward. It is also associated with fever and mild shortness of breath. She was first diagnosed with pericarditis about 5 years ago and was initially treated with high dose ibuprofen and short prednisone bursts. She has been having more severe and frequent recurrences for the last 2 years and has been on a combination of ibuprofen, colchicine and methylprednisone. She has recurrence of chest pain each time her steroids are weaned. She required pericardiocentesis twice in the last 5 years. She gained 30 pounds since being started on steroids. Workup was negative for autoimmune disease, tuberculosis and familial Mediterranean fever.

At her prior clinic visit, she was started on azathioprine for steroid sparing effect. She did well initially and was able to wean her methylprednisone to 20 mg daily. However, a week ago, she was diagnosed with right foot metatarsal fracture and a right hip fracture. Current medications include methylprednisone 20 mg daily, colchicine 0.6 mg BID, ibuprofen 200 mg BID, levothyroxine 75 mcg daily, cholecalciferol 1000 units daily, warfarin 5 mg daily and azathioprine 100mg daily. At this visit, she has a blood pressure of 150/78 mmHg, pulse of 92 beats per minute, respiratory rate of 14 per minute and BMI of 39.38 kg/m2. Physical exam revealed obesity, abdominal striae and few old bruises. Lungs were clear to auscultation, there was no jugular venous distention or pericardial rub but had trace pitting pedal edema. C-reactive protein is 29.5 mg/dL (Normal: <1 mg/dL), sedimentation rate is 47 mm/hr (Normal: 0-15 mm/hr). There are no ECG changes and an echocardiogram showed trivial pericardial effusion, normal left ventricular systolic and diastolic function, no significant valvular abnormalities, mild septal bounce, respiratory variation across the tricuspid valve of -63% and across mitral valve of 30%. IVC is dilated at 2.6 cm but collapses with inspiration. Cardiac MRI with gadolinium is shown in figure 1.

Figure 1: Cardiac MRI with gadolinium. Delayed enhancement image.

Figure 1
Pericardial delayed hyperenhancement (late gadolinium enhancement) on fat suppressed sequence with gadolinium.

Which of the following is the next best treatment option for this patient?

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