# Constrictive pericarditis requiring pericardiectomy: an unusual first presentation of extra-articular rheumatoid arthritis—a case report

## TL;DR

A man with no prior signs of rheumatoid arthritis was diagnosed with the condition after experiencing heart-related symptoms, highlighting an unusual first presentation.

## Contribution

This case report highlights pericardial constriction as a rare initial manifestation of extra-articular rheumatoid arthritis.

## Key findings

- Pericardial constriction was the first sign of rheumatoid disease in a patient without joint symptoms.
- Anti-CCP testing was crucial for confirming the diagnosis despite unhelpful pericardial pathology.
- Chronic inflammation and fibrosis, not calcification, can lead to constrictive physiology in rheumatoid pericarditis.

## Abstract

We report an unusual case of rheumatoid arthritis presenting for the first time with pericardial constriction and bilateral pleural calcification, in the absence of prior articular disease.

A 46-year-old Caucasian male, who initially presented with shortness of breath, intermittent chest tightness and general malaise, underwent extensive diagnostic workup over a period of six months involving multiple hospital admissions. He was found to have pericardial constriction on echocardiogram and ultimately required surgical pericardiectomy due to decompensation. After multiple diagnostic tests and specialist opinion, the aetiology of pericardial disease was ultimately confirmed to be extra-articular rheumatoid disease without synovitis.

Significant pericardial constriction can occur as the initial presentation of rheumatoid disease and anti-CCP is a highly specific confirmatory test. Pericardial pathological specimen can be unhelpful in determining this aetiology, and constrictive physiology can occur due to chronic inflammation/fibrosis in the absence of significant calcification.