Case Presentation: A 49-year-old Caucasian woman presented to the emergency department with fever, shortness of breath, chest pain, and abdominal pain. She had a five-to-six-month history of intermittent bilateral arthralgias in her knees, shoulders, and wrists. Physical exam was remarkable for a positive Murphy sign. Chest CT, and CXR showed an enlarged cardiac silhouette, with a follow up TTE demonstrating a pericardial effusion with evidence of right heart strain and respiratory variation consistent with tamponade physiology. ESR and CPR were elevated. CCP antibody test and rheumatoid factor were both positive; giving the patient a formal diagnosis of rheumatoid arthritis. HIDA scan was negative, suggesting a different etiology of abdominal pain in the RUQ than acute cholecystitis. Shortness of breath, abdominal pain and chest pain dramatically improved following the pericardiocentesis, with approximately 500mL of total volume removed. Pericardial drain was left in for 24 hours with repeat TTE demonstrating no reaccumulating fluid. High dose steroids were started per rheumatology recommendations with plan to transition to steroid-sparing regimen in the outpatient. Given the resolution of symptoms following the pericardiocentesis, it appears the root of pain in both sites and shortness of breath were from the pericardial effusion rather a separate etiology of abdominal pain. Patient was tapered from higher to lower dose of prednisone, and labs were ordered per protocol before starting the patient on methotrexate.

Discussion: RA is a systemic autoimmune disorder that typically presents with fever, weight loss and fatigue in addition to arthralgias. Patients will usually have other organ system involvement including skin, lungs, and heart. Although pericarditis is one of the more frequent cardiac manifestations seen in RA, it is not usually the initial presenting symptom seen in newly diagnosed RA patients. Further, abdominal pain with fever from pericarditis can be masquerading as acute cholecystitis, potentially delaying the recognition of an underlying autoimmune disorder and workup for RA.RA usually presents in populations above the age of 60, however, diagnosis should be considered in younger patients with the unique combination of concomitant fever, shortness of breath, chest pain, and abdominal pain. In our case, the ROS history was critical as it unveiled intermittent bilateral arthralgias as well as the inflammatory markers being markedly elevated for acute cholecystitis. Therefore, workup for RA (CCP, RF) may be warranted in the above clinical setting with elevated inflammatory markers. This also teaches to not anchor on the diagnosis of cholecystitis with a positive Murphy sign, and to rather be generally concerned with an inflamed peritoneum or pericardium. Imaging modalities should be chosen based off clinical presentation, but in the above case, the CXR and CT were pivotal points in choosing a TTE and ultimately performing a pericardiocentesis, so a low threshold to image these patients should be considered. This case highlights the importance of diagnosing and treating both acute and underlying chronic autoimmune conditions early. This is particularly important in patients who may not classically fit the demographic of rheumatoid arthritis.

Conclusions: RA workup (CCP, RF) should be considered with elevated inflammatory markers and cardiomegaly consistent with acute pericarditis on imaging, even if the patient does not classically fit the demographic of RA.