Key points are not available for this paper at this time.
Background We present three varying rheumatological disorders with complex cardiac involvement and the sequalae of immunosuppression. Objectives To highlight complete heart block (CHB) and arrhythmias in acute connective tissue (CT) flares could be managed conservatively without the need for pacing. To describe the impact of severe systemic immune mediated inflammatory disorders on the heart and concomittant adversity from disease modifying antirheumatic drugs (DMARDS) Methods/History of present illness Case 1 A 30-year-old lady with mixed CT disorder (lupus, rheumatoid arthritis and myositis anti Ro/SSM antibody positive) was hospitalised with pneumococcal meningitis resulting soon after pulsed methylprednisolone and mycophenolate mofetil immunosuppression. Case 2 A 59-year-old lady with systemic sclerosis and severe pulmonary hypertension (PHTN), restrictive hypertrophic cardiomyopathy, chronic small pericardial effusion and right heart failure. She presented with worsening breathlessness, complete left bundle branch block (LBBB), atrial flutter and enlargement of pericardial effusion. Case 3 A 28-year-old lady with rheumatoid arthritis (RA) flare and recurrent chest pain from acute pericarditis. ECG sinus tachycardia with PR depression. Results Case 1 Meningitis was treated, DMARDs were halted during fulminant sepsis, consequently hypotension secondary to cardiac tamponade from acute myo/pericarditis ensued necessitating pericardiocentesis. Initially sinus tachycardia followed by new right bundle branch block and then CHB (figure 1). Cardiomyopathy with pseudoinfiltrative pattern developed. Steroids and supportive therapy with isoprenaline resolved the conduction defects without pacing. Case 2 Sepsis from Group A streptococcus resulted after enhanced immunosuppressants. ECG showed sinus rhythm complete LBBB. Chest x-ray (CXR) showed massive cardiomegaly. Echocardiogram revealed large global pericardial effusion, PHTN but no vegetations. She continued to deteriorate despite antibiotics and supportive therapy. Palliative pericardiocentesis was undertaken but pericardial decompression syndrome occurred. She palliated and succumbed to her illness. Case 3 Treated for acute RA flare with serositis with colchicine, steroids and methotrexate. High serum inflammatory markers. CXR showed left pleural effusion. Echocardiogram showed pericardial effusion, bright pericardium and fibrinous strands. Cardiac MRI showed late gadolinium enhancement globally across the pericardium and septal bounce suggestive of early effusive constrictive pericarditis. Repeat imaging post DMARDS showed resolution of pericardial and pleural effusions. (Figure 2) Conclusions Autoimmune rheumatological disorders may cause pan cardiac involvement, although heart block and cardiac tamponade are rare complications. Immunosuppression remains the primary treatment and may reverse conduction block, arrhythmia and myo/pericarditis, its consequences are not to be dismissed. New DMARDs may require cardio-rheumatology specialists. Conflict of Interest None
Gan et al. (Mon,) studied this question.