Massive Pericardial Effusion Secondary to Mesalamine Therapy in Ulcerative Colitis

Abstract

Purpose: Mesalamine is the most commonly used drug for mild to moderate ulcerative colitis. We report a rare occurrence of massive pericardial effusion secondary to mesalamine usage requiring pericardiocentesis. Case Report: A 54 yr old female presented to emergency room with symptoms of palpitations and dyspnea. She was recently diagnosed to have biopsy proven ulcerative colitis 3 months ago and started on mesalamine therapy 8 weeks ago along with tapering dose of prednisone. She was taking 2.4 gm of mesalamine once daily. On physical examination she was found to have tachycardia with heart rate of 140 beats/min and muffled heart sounds. EKG showed sinus tachycardia with no changes of acute pericarditis. CT scan of her chest revealed a large volume pericardial effusion. Further echocardiogram confirms massive pericardial effusion with cardiac pretamponade. She underwent an urgent percardiocentesis and symptoms were relieved successfully. Pericardial fluid was trasudative. She had further extensive work up to find out etiology of this presentation which has ruled out any malignancy, autoimmune disease, viral or bacterial infection. Her pericardial effusion was considered secondary to mesalamine and it was discontinued. Follow up echocardiogram did not show any re-accumulation of pericardial effusion. Discussion: Pericarditis and pericardial effusion are extremely infrequent side effects of mesalamine. The exact mechanism of mesalamine induced cardiac complications is unclear. Most possible mechanisms includes direct cardiotoxic effect, an IgE-mediated allergic reaction, a cell mediated hypersensitivity reaction or a humoral antibody response. The decision whether pericarditis is drug induced or extraintestinal manifestation of underlying inflammatory bowel disease (IBD) is not easy. The rapidity of onset of symptoms with initiation of drug and resolution soon after stopping the drug suggests that they were drug induced. Treatment of drug related pericarditis and pericardial effusion includes the immediate cessation of the responsible drug as well as pericardiocentesis if needed. NSAIDS should not be used in the treatment as they can aggravate ulcerative colitis. Steroids can be beneficial but not entirely proven. Underlying IBD should be treated with alternate medication. Similar cardiac complications secondary to azathioprine has been rarely reported, so better to be avoided in these patients. Conclusion: Pericarditis and pericardial effusion, albeit a rare occurrence, should be considered in patients with inflammatory bowel disease who present with cardiac symptoms and are being treated with mesalamine.