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Adalimumab/infliximab/vedolizumab Recurrent pericarditis: case report

A 13-year-old boy developed recurrent pericarditis during treatment with infliximab, adalimumab, and vedolizumab for Crohn’s colitis [dosages not stated; not all routes stated]. The boy presented to the emergency department in July 2017 due to left sided and central chest pain that was radiating to the left shoulder and back since a day. He also had fever, shortness of breath and malaise. At presentation, he was lethargic with a HR of 80 beats/minute. Upon examination, a pericardial rub was noted. His chest X‑ray revealed mild cardiomegaly with clear lungs. His electrocardiogram (ECG) demonstrated changes in the ST‑T wave, suggestive of pericarditis. Laboratory tests showed anaemia, increased level of C‑reactive protein and normal level of serum troponin. His initial echocardiogram showed pericardial effusion along with normal biventricular systolic function. A CT scan of the chest showed pleural effusion bilaterally along with a pericardial effusion without calcification or thickening of pericardium. Hence, he was hospitalised. The boy underwent pericardiocentesis and turbid yellow fluid was drained. A pericardial drain removal was carried out a couple of days after. He was treated with hydrocortisone for pericarditis and pleural effusion with a good response. Thereafter, he was treated with prednisone that was weaned over a period of several weeks. His laboratory work-up was negative for infection. An endoscopy showed remission of his Crohn’s colitis. Four months later (in November 2017), he again presented to emergency department due to recurrence of the chest pain, fever and increase in C‑reactive protein. His repeated ECG showed abnormal changes in ST‑T waves and the echocardiogram showed normal function along with a small pericardial effusion. Therefore, he was treated with unspecified steroids followed by ibuprofen that led to improvement of the symptoms. However, he again presented due to chest pain, for which he received a prednisone. Subsequently, his echocardiogram demonstrated resolution of the pericardial effusion with a normal ECG results in December 2017. In January 2018, he again experienced recurrent chest pain and fever, which was treated with unspecified steroids followed by colchicine. In October 2018, he developed severe weakness that required hospitalisation. He underwent a repeat colonoscopy that confirmed remission of Crohn’s disease. Myasthenia gravis was ruled out upon further investigations. His brain MRI was normal, and it was considered that his symptoms were related to the decreased ferritin level and autonomic dysfunction. Hence, he received iron therapy. During the hospitalisation, it was suspected that the fatigue and weakness were possibly related to the chronic use of colchicine. Hence, colchicine therapy was gradually stopped. Six weeks after the discontinuation of colchicine, he again developed shortness of breath and positional chest pain (symptoms of pericarditis), and his