She also had remote colon cancer treated with partial colectomy. On arrival to the ED, she was afebrile, had tachypnea and tachycardia with stable blood pressure. 1972 as a distinct entity of connective tissue disease [1]. The disease is characterized by overlapping features characteristic of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc), and polymyositis/dermatomyositis (PM/DM), along with the presence of antibodies to ribonucleoprotein (anti-RNP) [2]. The disease has a wide AN-3485 spectrum of clinical manifestations due to the involvement of various body organs including the heart. Pericarditis is the most common cardiac manifestation of the disease and can affect all layers of the heart. Tamponade on the other hand is a rare manifestation of the disease with limited literature describing such presentation. Here we describe the case of an 81-year-old female who presented with new onset hemorrhagic pericardial effusion requiring drainage and pericardial windows. Pericardial tissue biopsy showed fibrinous pericarditis and further serology confirmed positive anti-RNP. The patients condition was controlled with steroids and follow-up echocardiogram showed resolution of the pericardial effusion. Case Report An 81-year-old female presented to the emergency department (ED) complaining of progressive shortness of breath over the preceding few weeks. Other symptoms include weight loss of 30 lb over 5 months, pain in both knees and hips, as well as swelling and numbness in her right-hand fingers. Patient had been following regularly at the cardiology clinic. She had extensive past medical history significant for chronic kidney disease (CKD) stage III, hypertension, coronary artery disease and history of remote myocardial infarction complicated by right ventricular (RV) aneurysm with mural thrombus treated with warfarin therapy, and sick sinus syndrome managed with a pacemaker. She also had remote colon cancer treated with partial colectomy. On arrival to the ED, she was afebrile, had tachypnea and tachycardia with stable blood pressure. Physical exam revealed fine crackles along the bases and absent pedal edema. She had wide spread hyper pigmented macules and papules over the back and extremities. Initial laboratory workup showed creatinine 2.84 mg/dL, hemoglobin (Hb) 8.2 g/dL, brain natriuretic peptide (BNP) 317 pg/mL and normal troponin level. Electrocardiogram (EKG) showed ST changes along AN-3485 the inferior leads with low voltage QRS (Fig. 1). Transthoracic echocardiography (TTE) revealed a large circumferential pericardial effusion with tamponade physiology (Fig. 2). Previously seen RV mural thrombus was not identified. Pericardiocentesis was performed with 700 mL of frankly bloody pericardial fluid drained, and a pigtail catheter was left in place for passive dependent drainage (Fig. 3). Pericardial fluid analysis showed a hemorrhagic exudate without evidence of contamination or malignancy based on normal microbiology studies and cytology results. Open in a separate window Physique 1 EKG shows sinus rhythm with occasional premature ventricular complexes and low voltage QRS. Open in a separate window Rabbit Polyclonal to MNK1 (phospho-Thr255) Physique 2 Transthoracic echocardiography, subcostal four chamber view showing diastolic collapse of the RV. Open in a separate window Physique 3 CT scan of the chest shows pigtail catheter coursing within the pericardium and around the anterolateral heart border with tip terminating posterior to the left atrium. Mild to moderate residual pericardial effusion along the inferior AN-3485 heart border. Bilateral pleural effusions, small to moderate around the left and small on the right. Moderate to severe emphysematous changes. Further assessments showed an erythrocyte sedimentation rate (ESR) 109 mm/h, C-reactive protein (CRP) 10.5 mg/L and normal thyroid function test. She had positive serology for ribonucleoprotein antibodies at 1.9 in keeping with a diagnosis of MCTD. Further serology testing were adverse for anti-dsDNA, ribosomal P proteins, anticentromere Ab, Sjogrens symptoms B and A, Jo1 Ab and Scl-70 Ab. Computed tomography (CT) scan from the upper body, abdominal, and pelvis demonstrated no proof malignancy, and tumor.