A Case of Autoimmune Pericarditis and its Management
This is a 30-year-old female who has a history of systemic lupus erythematosus (SLE) for 6 years. Two years ago, she was admitted to an outside hospital for shortness of breath where she was found to have bilateral pleural effusion (more on the left side) and underwent left sided thoracentesis. She was also experiencing central, non-radiating, pleuritic chest pain that worsened in supine position. There were no electrocardiogram changes, but physical examination revealed a pericardial friction rub. Westergren sedimentation rate (WSR) was 10 mm/hour (reference range: 0-20 mm/hour) and C-reactive protein (CRP) was 0.2 mg/dL (reference range: <0.9 mg/dL). An echocardiogram was performed which revealed trace pericardial effusion. Cardiac magnetic resonance (CMR) revealed mild focal increased pericardial signal intensity anterior/inferior to the right ventricle suggesting edema on T2 short tau inversion recovery (STIR) imaging (Figure A). Phase sensitive inversion recovery (PSIR) sequence after contrast administration showed mild circumferential late gadolinium enhancement (LGE) reflecting inflammation/fibrosis (Figure B). With the diagnosis of lupus induced acute pericarditis, she was started on ibuprofen 800 mg twice a day, colchicine 0.6 mg once a day (which she took only for 3 months) and tapering regimen of prednisone over 6 months which she was eventually switched to steroid sparing agents, mycophenolate mofetil (MMF) 1000 mg twice daily and hydroxychloroquine 200 mg once daily. Five months prior to presentation, she was treated with prednisone, which was tapered over 10 days, for lupus flare which manifested as severe diffuse arthralgias. Now, she presented to our clinic with worsening pleuritic chest pain which got relieved by leaning forward. She was hemodynamically stable. Physical examination reflected a pericardial friction rub. WSR was 15 mm/hour (reference range: 0-20 mm/hour) and (CRP) was 1 mg/dL (reference range: <0.9 mg/dL). Current medication included ibuprofen 800 mg once daily, MMF 1000 mg twice daily and hydroxychloroquine 200 mg once daily. CMR was obtained which revealed moderate circumferential pericardial increased signal on T2 STIR imaging (Figure C). PSIR sequence after contrast administration showed moderate circumferential LGE suggestive of active pericardial inflammation (Figure D). There was slight interval worsening noted as compared to the previous study (Figure A and B).
What is the next best step of management?