Myopericarditis in a Patient With Ulcerative Colitis on Mesalamine and Prednisone: Case Report and Review of Literature

Abstract

Introduction: Myopericarditis is a pericarditic syndrome with minor myocardial involvement. The diagnostic criteria include evidence of pericarditis with elevation of cardiac inflammatory biomarkers or reduced left ventricular function without wall motion abnormalities shown on echocardiography. We report a case of acute myopericarditis in a patient with ulcerative colitis (UC) who was started on mesalamine and prednisone. A 25-year-old male with recently diagnosed ulcerative colitis presented to the hospital with hematochezia and abdominal pain. On presentation, the physical exam was only significant for mild abdominal tenderness to palpation in the bilateral lower quadrants. Laboratory exam was significant for a leukocytosis of 15.6 K/uL, elevated erythrocyte sedimentation rate of 68 MM/HR, and elevated C-reactive protein of 137 mg/L. Computed tomography of abdomen and pelvis with contrast showed diffuse wall thickening of the distal colon with mild pericolonic fat stranding, consistent with UC. A repeat colonoscopy showed evidence of moderately severe UC in the transverse, descending, and sigmoid colon, and rectum. The patient was subsequently started on mesalamine 2.4 g and prednisone 50 mg daily. About 3 weeks later, the patient developed low-grade fever, new onset sharp substernal chest pain with worsening of pain on inspiration and lying flat. His electrocardiography showed typical diffuse ST elevation with PR depression, except in lead aVR. Troponin I was elevated at 0.3 ng/mL. An echocardiogram performed at the time showed left ventricular systolic function to be at the lower limits of normal, estimated at 50-55% with small circumferential pericardial effusion. Mesalamine was stopped, with resolution of chest pain and fever in 4 days. The pathophysiology of this condition is thought to be humoral-mediated hypersensitivity reaction against 5-aminosalicylic acid regimen. The antibodies developed cross-react with the pericardium, causing inflammation. This diagnosis is supported by 2 facts in all reported cases. Worsening of inflammation if mesalamine is reintroduced during acute phase and resolution of symptoms within 1 week after the discontinuation of mesalamine. In conclusion, we present a case of mesalamine-induced myopericarditis in a patient already on prednisone that was successfully resolved by discontinuation of the medication. Because mesalamine-induced myopericarditis is very rare but could be fatal, clinicians should be aware of this potential drug-related reaction and make an early and accurate diagnosis of this condition for prompt treatment.