A RARE CASE OF CARDIAC TAMPONADE IN THE SETTING OF ULCERATIVE COLITIS

Document Type

Conference Proceeding

Publication Date

6-27-2024

Publication Title

J Gen Intern Med

Keywords

antihypertensive agent, colchicine, ibuprofen, mesalazine, abdominal pain, adverse drug reaction, cardiomegaly, cardiotoxicity, case report, clinical article, conference abstract, cross reaction, diagnosis, diarrhea, drug therapy, dyspnea, echocardiograph, echocardiography, electrocardiogram, electrocardiography, emergency ward, female, follow up, heart tamponade, hemodynamics, human, hypotension, macrophage, molecular mimicry, neutrophil, oral drug administration, pericardiocentesis, pericarditis, pericardium, side effect, ST segment elevation, tachycardia, therapy, thorax pain, thorax radiography, ulcerative colitis

Abstract

CASE: A 33-year-old female with a history Ulcerative Colitis and medication nonadherence to Mesalamine presented to an outside facility with shortness of breath and chest pain. Her initial workup proved unremarkable, so she was sent home with Ibuprofen and follow-up. Her chest pain progressively worsened, she developed abdominal pain with diarrhea, and she returned to the Emergency Department. On arrival, she was tachycardic (126), hypotensive (98/54), ill-appearing, and diaphoretic. An electrocardiogram (EKG) demonstrated diffuse STsegment elevation, while her chest radiograph showed a mildly enlarged cardiac silhouette. An urgent transthoracic echocardiogram (TTE) was ordered, demonstrating excessive respiratory variation and mitral valve and tricuspid valve spectral Doppler velocities (more than 25% and 40%, respectively) with evidence of tamponade. Given these findings, she was transferred to our facility for further care. She underwent urgent pericardiocentesis yielding 350 mL of exudative fluid, with high neutrophils and inflammatory markers, but negative fluid culture. Repeat echocardiogram demonstrated resolution of tamponade. GI was consulted given UC flare concerns; she was started on mesalamine 1000 mg four times/day along with colchicine 0.6mg twice a day. Her abdominal pain and diarrhea improved, and she was discharged on this medication regimen. IMPACT/DISCUSSION: Cardiac Tamponade is a syndrome wherein the pericardial space accumulates sufficient fluid to produce impairment of diastolic filling, leading to hemodynamic instability and shock. Extraintestinal manifestations of Inflammatory Bowel Disease (IBD) are common in 25- 40% of patients, and of the rare cardiovascular manifestations of IBD, pericarditis is the most common. Although the exact etiology of this phenomenon is unknown, current hypotheses include autoimmune inflammation and/or direct cardiotoxicity of antiinflammatory medication used in IBD. Patients with mild to moderate UC can be treated with biologic agents such as mesalamine, which impedes macrophages and reduces the native inflammatory response. Paradoxically, mesalamine has been reported to cause pericarditis due to molecular mimicry, causing cross-reactivity between myocardial antigens and mesalamine's molecular structure. Our patient stated she only took her Mesalamine once daily instead of the prescribed four times/day regimen. CONCLUSION: We report a case of Cardiac Tamponade in a UC patient on subtherapeutic Mesalamine. We suspect the likely etiology of her presentation involves a possible molecular mimicry phenomenon, supported by the fact she was on subtherapeutic doses of Mesalamine that could cause cross-reactivity and inflammation, while the anti-inflammatory properties of the drug were insufficient. Once she started adequate dosing of Mesalamine, she experienced swift resolution in her symptoms.

Volume

39

First Page

S251

Last Page

S252

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