Cholesterol crystals in pericardial effusion associated with rheumatoid arthritis

Excerpt

A 60-year-old female patient with rheumatoid arthritis for 7 years, in disease remission under treatment with methotrexate and leflunomide, was admitted to the emergency room because of an echocardiogram performed in an external service showing moderate pericardial effusion. The examination was repeated and a large pericardial effusion with signs of cardiac restriction was observed. The patient underwent pericardiocentesis with the removal of 400 mL of turbid yellow liquid. The fluid had the characteristics of exudate with high protein (4.5 g/dL), lactate dehydrogenase (1198 U/L), leucocytes (61.6/mm³), glucose (13 mg/dL), cholesterol (164 mg/dL), and triglycerides (< 15 mg/dL), as well as a massive presence of cholesterol crystals on microscopy (Fig. 1). The cultures of aerobic bacteria, mycobacteria, and fungi were negative. Viral serology, inflammatory test results, lipid profile, blood count, renal function, liver enzyme levels, and thyroid-stimulating hormone were normal. Therapy with methotrexate and leflunomide was maintained, and colchicine (1 mg/day) and prednisone (40 mg/day) were added to the treatment, with complete resolution of pericardial effusion. Pericarditis due to cholesterol crystals is an uncommon manifestation of rheumatoid arthritis, set when concentration of cholesterol in the pericardial fluid is elevated (> 70 mg/dL), and is associated with the chronicity of the disease [1, 2]. Other associations include hypothyroidism and tuberculosis, but the main cause would be idiopathic, all characterized by large chronic effusions, with fluid analysis being essential for diangostic elucidation. When associated with autoimmune diseases, immunosuppressive treatment is necessary. However, it is marked by frequent recurrences, requiring regular follow-up [3]. During follow-up, in addition to clinical evaluation, the patient underwent echocardiography at 3 and 6 months with no alarm findings for recurrence. After 6 months, the patient kept using immunosuppressants and colchicine with good tolerance, besides a progressive reduction of prednisone (currently 10 mg/day).

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