Is There a Benefit of Performing Serial Cardiac Magnetic Resonance Imaging in a Patient with Recurrent Pericarditis?
A 53-year-old female is seen at our clinic as follow up for recurrent idiopathic pericarditis. Patient initial presentation was almost 6 years ago when she presented with left sided chest pain, pleuritic in nature, worsened with movement and deep breaths, radiating towards left shoulder which limited her daily activities to the extent that she was bedridden. She had no associated shortness of breath, orthopnea, weight gain, leg swelling or syncope. She had multiple recurrences requiring emergency room visits. Her medical history includes Factor V Leiden mutation and hypothyroidism. Her brother was diagnosed with pericarditis at age 27. Her physician told her that "some of your markers are suggestive of lupus". Chest computerized tomography (CT) scan performed at time of initial presentation showed moderate pericardial effusion. Erythrocyte sedimentation rate (ESR) was 44 mm/hr, ultrasensitive C-reactive protein (usCRP) was 170 mg/L. She was started on ibuprofen, colchicine and prednisone.
She was referred to our clinic and her initial work up showed ESR of 27mm/hr (normal 0-15 mm/hr), usCRP 31 mg/L (normal <3mg/L), NT pro BNP of 400 pg/mL and antinuclear antibody titer of 1:320 (normal ≤1:40). Electrocardiogram showed non-specific ST-T wave abnormalities. Viral testing for Coxsackie and echovirus was negative. Cardiac magnetic resonance imaging (CMR) showed moderate enhancement of the pericardium on late gadolinium enhancement T1 sequence, increased signal on T2 edema weighted imaging consistent with active pericarditis without any features of constriction (Figure 1a and 1d, respectively). We continued her triple therapy with colchicine, ibuprofen and prednisone.
During subsequent years, she developed multiple recurrences with pleuritic chest pains and elevated inflammatory markers. Follow-up CMR a year later showed mild circumferential delayed enhancement of pericardium and edema of pericardial layer (Figure 1b and 1e respectively). Prednisone dose was adjusted to attain better symptomatic control. Over subsequent months, attempt was made to taper her from steroids to avoid side effects She failed trial of azathioprine and was eventually started on anakinra after which prednisone and colchicine was gradually tapered off.
During this current office visit, she describes no chest pain. Her blood pressure was 90/62 mmHg, pulse 60 beats per minute, oxygen saturation 98% on room air. On examination, her lungs sounds were clear, S1 and S2 regular with no murmurs or pericardial knock. No jugular venous distention, Kussmaul's sign, and no peripheral edema was noticed. Her ESR was 2 mm/hr and usCRP was 1.1 mg/L. Her CMR showed only minimal pericardial enhancement, no pericardial edema or thickening or constriction (fFgure 1c & 1f, respectively). Since she had no further recurrences, her anti-inflammatory therapy, including anakinra, was gradually tapered off. Clinical recovery was evident as she can now tolerate her routine activities, walk 10,000 steps per week and perform pilates 2-3 times a week.
Which of the following best explains the utility of performing serial CMR in this patient?