ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Pericardial involvement in systemic autoimmune diseases

Pericardial involvement in systemic autoimmune diseases
Literature review current through: Jan 2024.
This topic last updated: Dec 07, 2022.

INTRODUCTION — Systemic autoimmune diseases, also known as systemic inflammatory diseases, are inflammatory syndromes involving at least two organ systems. Classical systemic inflammatory diseases include connective tissue diseases, vasculitis, and granulomatous diseases (table 1).

This topic will focus on the pericardial complications of systemic autoimmune diseases. A detailed discussion of non-pericardial cardiac manifestations of systemic autoimmune diseases is presented separately. (See "Non-coronary cardiac manifestations of systemic lupus erythematosus in adults" and "Overview of the systemic and nonarticular manifestations of rheumatoid arthritis", section on 'Cardiac disease' and "Clinical manifestations and diagnosis of cardiac sarcoidosis".)

SPECTRUM OF CARDIAC INVOLVEMENT IN SYSTEMIC INFLAMMATORY DISEASES — Cardiac involvement is not uncommon in systemic inflammatory diseases, although major cardiac problems are not usually the presenting manifestation. The frequency of cardiac manifestations in various systemic autoimmune diseases is not well established. The frequency of cardiac involvement is variable depending on the diagnostic method applied and patient selection. Technological improvements in imaging modalities and the increasing availability of diagnostic imaging have revealed a higher frequency of cardiac abnormalities in patients with systemic inflammatory diseases than in older autopsy studies.

Systemic inflammatory diseases may affect one or more of the following components of the cardiovascular system:

Pericardial disease – Studies suggest that the majority of cases of pericardial effusion are related to systemic disease and not to primary heart disease. Pericardial effusion and/or pericarditis commonly present as manifestations of a known systemic disease. In these cases, pericardial involvement generally reflects the activity of the systemic disease and, in some clinical settings, may suggest an adverse prognosis. On rare occasions, pericardial effusion or pericarditis may be the first clue of a systemic inflammatory disease. (See "Pericardial effusion: Approach to diagnosis", section on 'Identifying the etiology'.)

Nonpericardial disease – Patients with systemic inflammatory diseases with pericardial involvement commonly also have nonpericardial cardiovascular manifestations:

Myocardium (myocarditis, cardiomyopathy, rhythm and conduction disturbances, heart failure)

Coronary arteries (acute coronary syndromes, ischemic heart disease)

Endocardium (valvular disease, thrombi)

Arterial and venous systems (which may manifest as arterial aneurysm formation, arterial and venous thrombosis)

CLINICAL PRESENTATION, DIAGNOSIS, AND TREATMENT — The most common types of pericardial involvement with systemic inflammatory diseases are acute (or recurrent) pericarditis and asymptomatic pericardial effusions [1]. Pericardial involvement in systemic inflammatory disease is thought to be immune-mediated, although concomitant infection may play a role in some cases. Systemic inflammatory diseases may be either "etiologic" or "permissive" of increased susceptibility to an unrelated primary cause (eg, viral) [2].

While some patients may manifest with the typical signs and symptoms of pericarditis (fever, pleuritic chest pain) or a hemodynamically significant effusion (dyspnea, fatigue, hypotension), many are incidentally found to have pericardial involvement during testing for other indications (electrocardiography, echocardiography, computed tomography of the chest, or magnetic resonance imaging of the heart). Symptoms of pericardial involvement in systemic inflammatory disease may be insidious or may present suddenly with rapid progression. Cardiac tamponade and constrictive pericarditis are possible, but rare, complications. (See "Acute pericarditis: Clinical presentation and diagnosis", section on 'Clinical features' and "Pericardial effusion: Approach to diagnosis", section on 'Cardiac imaging'.)

A definitive diagnosis of pericardial involvement in systemic inflammatory diseases requires the finding of specific histological lesions in the pericardium or of characteristic pericardial fluid features [2]. However, in clinical practice, the diagnosis is often presumptive, especially when pericardial fluid or tissue is not available (as in mild pericardial involvement with small to moderate effusions that are responsive to medical therapy) [3]. (See "Pericardial effusion: Approach to diagnosis", section on 'Identifying the etiology'.)

The treatment approach to pericardial involvement in systemic inflammatory diseases is dependent on symptoms. When a patient with pericardial involvement is asymptomatic, treatment is essentially that of the underlying systemic disease. Patients with a hemodynamically significant pericardial effusion should have the fluid drained (eg, pericardiocentesis or pericardiotomy) [3]. Most patients with symptoms of acute pericarditis should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine (table 2). In select patients with refractory symptoms despite optimal medical therapy, case reports suggest that the interleukin receptor blocker anakinra may be effective in reducing symptoms and signs of inflammation [4-6]. (See "Recurrent pericarditis", section on 'Other immune therapy'.)

Rarely, a patient may develop constrictive pericarditis. Treatment of early (subacute) and late (chronic) constrictive pericarditis is discussed separately. (See "Constrictive pericarditis: Diagnostic evaluation".)

SPECIFIC SYSTEMIC INFLAMMATORY DISEASES WITH PERICARDIAL INVOLVEMENT

Connective tissue diseases — Pericardial involvement, especially asymptomatic, is relatively common in many connective tissue diseases (table 3).

Systemic lupus erythematosus — Pericardial involvement may precede the clinical signs of systemic lupus erythematosus (SLE). Pericardial involvement, typically a pericardial effusion, is the most common type of echocardiographic abnormality found in SLE, being reported in >50 percent of patients, and is usually asymptomatic. Large and/or hemodynamically significant effusions resulting in cardiac tamponade are rare in SLE, as is the late development of constrictive pericarditis [7,8]. When pericardial fluid is available for analysis, specific findings may include antinuclear antibodies, phagocytic cells containing nuclei, low complement levels, and immune complexes similar to those seen in pleural effusions. However, in clinical practice, such findings in pericardial fluid add little to similar tests performed on a patient's serum. (See "Non-coronary cardiac manifestations of systemic lupus erythematosus in adults", section on 'Pericardial disease'.)

Pericarditis is the second most frequent type of pericardial involvement, either acute or recurrent. Pericarditis often occurs when SLE is active and may be associated with other types of serositis (ie, pleural effusion, ascites). The course is generally benign in the large majority of patients with pericardial disease. When symptomatic, however, patients with pericarditis usually respond to nonsteroidal anti-inflammatory drugs (NSAIDs) (table 2). When given along with NSAIDs, colchicine may reduce the risk of recurrent pericarditis [8-10]. Patients who do not tolerate or respond to NSAIDs and colchicine can be treated with a corticosteroid, usually prednisone. (See "Acute pericarditis: Treatment and prognosis", section on 'Treatment'.)

Rheumatoid arthritis — Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder that primarily involves joints, although extraarticular features (eg, anemia, fatigue, pleuropericarditis, neuropathy, renal disease) may occur. During the course of their disease, <10 percent of patients with rheumatoid arthritis will develop pericarditis, although up to one-third have pericardial effusions which are usually asymptomatic. Pericarditis occurs most frequently in patients with active rheumatoid disease and other extra-articular manifestations. As such, most patients with symptomatic pericarditis have a positive serum test for rheumatoid factor. Management should be aimed at the control of the rheumatoid arthritis, though NSAIDs and colchicine can be given for symptomatic pericarditis (table 2) [11]. Occasionally, patients with RA develop constrictive pericarditis requiring pericardiectomy as definitive treatment. (See "General principles and overview of management of rheumatoid arthritis in adults".)

Adult-onset Still disease — Still disease (also called systemic juvenile inflammatory arthritis) is an inflammatory disorder characterized by daily fevers, arthritis, and an evanescent, salmon-colored rash typically found on the trunk. In the 70s, the term "adult-onset Still disease" (AOSD) was used to describe a series of adult patients who did not fulfill criteria for classic rheumatoid arthritis (RA) but had features similar to the children with systemic juvenile RA. Pericarditis has been reported in up to one-third of patients, and myocarditis in about 10 percent [12,13]. (See "Clinical manifestations and diagnosis of adult-onset Still's disease".)

Systemic sclerosis — Systemic sclerosis is an autoimmune disorder in which the characteristic skin changes of scleroderma are present in association with internal organ involvement. When present, cardiac complications are most commonly secondary to systemic or pulmonary hypertension, but primary cardiac involvement also occurs. Symptomatic pericarditis occurs in 7 to 20 percent of patients with systemic sclerosis, but pathologic evidence of pericardial involvement is observed in 70 to 80 percent of patients at autopsy. Pericardial effusions may be small or large and can develop rapidly, also leading to cardiac tamponade [14,15]. Patients with symptomatic cardiac involvement due to systemic sclerosis (SS) have a poor prognosis, with two- and five-year mortality rates of approximately 60 and 75 percent, respectively. When pericardial effusion is present along with pulmonary hypertension, the prognosis is worse. (See "Clinical manifestations and diagnosis of systemic sclerosis (scleroderma) in adults", section on 'Cardiac involvement'.)

Dermatomyositis and polymyositis — Both polymyositis and dermatomyositis are classified as idiopathic inflammatory myopathies. While both dermatomyositis and polymyositis share the clinical feature of muscle weakness, dermatomyositis is also associated with a variety of characteristic skin manifestations. Cardiac involvement in polymyositis and dermatomyositis usually is asymptomatic and rarely the principal clinical feature at the time of initial presentation. Pericardial involvement is less common than for other connective tissue diseases (<10 percent) and may be manifested by acute pericarditis, pericardial effusion, and cardiac tamponade [16,17]. (See "Clinical manifestations of dermatomyositis and polymyositis in adults".)

Mixed connective tissue disease — Mixed connective tissue disease (MCTD) is a generalized connective tissue disorder characterized by the presence of high titer anti-U1 ribonucleoprotein antibodies in combination with clinical features commonly seen in systemic lupus erythematosus, scleroderma, and polymyositis. Pericarditis is a relatively common clinical manifestation in MCTD, being reported in 10 to 30 percent of patients. However, pericardial tamponade is rare. Involvement of the myocardium is also increasingly recognized in MCTD [18]. (See "Mixed connective tissue disease".)

Sjögren's disease — Sjögren's disease is a chronic inflammatory disorder characterized by diminished lacrimal and salivary gland function, although extraglandular disease involvement can involve nearly any organ. Cardiovascular involvement occurs in less than one-third of cases and is usually asymptomatic. Pericarditis (both acute and recurrent) is the most common form of cardiac involvement in Sjögren's disease [19]. (See "Clinical manifestations of Sjögren’s disease: Extraglandular disease", section on 'Heart and cardiovascular system'.)

Other disease entities

Sarcoidosis — Sarcoidosis is a multisystem granulomatous disorder of unknown etiology that is characterized pathologically by the presence of noncaseating granulomas in involved organs. Clinical manifestations of cardiac sarcoidosis depend upon the location and extent of granulomatous inflammation. Cardiac involvement (which affects about 25 percent of patients) may precede, follow, or occur concurrently with involvement of the lungs or other organs. Clinicians should consider the possibility of sarcoid heart disease in the evaluation of an otherwise healthy young or middle-aged person with cardiac symptoms or of a patient with known sarcoidosis who develops arrhythmias, conduction disease, or heart failure. Mild to moderate asymptomatic pericardial effusions are commonly detected. However, symptomatic pericarditis is rare during the course of the disease [20]. (See "Clinical manifestations and diagnosis of cardiac sarcoidosis".)

Pericarditis in acute rheumatic fever — Acute rheumatic fever can occur two to four weeks following group A streptococcus pharyngitis and may consist of arthritis, carditis, chorea, erythema marginatum, and subcutaneous nodules. Rheumatic fever in general and pericarditis associated with rheumatic fever have become relatively rare in developed countries due to the routine use of antibiotics for pharyngitis. Acute pericarditis is a sign of active rheumatic carditis, usually occurring at the initial episode in the first week following fever and arthritis. Occasionally pericarditis may be the first sign of acute rheumatic fever. (See "Acute rheumatic fever: Clinical manifestations and diagnosis".)

Pericardial rub is generally intense, and pericardial effusion is common although cardiac tamponade is generally rare. On this basis, rheumatic fever-associated pericarditis without definite carditis should be suspected in the presence of fever and arthritis in a young patient with serologic testing that is positive for beta-hemolytic streptococci. Treatment of pericarditis associated with rheumatic fever is the same as other causes of acute pericarditis (table 2), with NSAIDs and colchicine as first line treatment options. Corticosteroids may be prescribed in cases of NSAID failure or contraindication [2]. (See "Acute pericarditis: Treatment and prognosis", section on 'Treatment'.)

Vasculitis — The vasculitides are defined by the presence of inflammatory leukocytes in vessel walls with reactive damage to mural structures. Loss of vessel integrity may lead to bleeding. Luminal compromise leads to downstream tissue ischemia and necrosis. Vasculitis may occur as a primary process or may be secondary to another underlying disease. In general, affected vessels vary in size, type, and location in association with the specific vasculitic disorder. Classically, the vasculitic syndromes have been categorized by the predominant sizes of the involved blood vessels (table 4). (See "Overview of and approach to the vasculitides in adults", section on 'Nomenclature'.)

The presence of vasculitis should be considered in patients who present with systemic symptoms in combination with evidence of single and/or multiorgan dysfunction. Although neither sensitive nor specific, common complaints and signs of vasculitis include fatigue, weakness, fever, arthralgias, abdominal pain, hypertension, renal insufficiency (with an active urine sediment containing red and white cell and occasionally red cell casts), and neurologic dysfunction. Pericardial involvement is relatively rare in large vessel vasculitis (eg, Takayasu arteritis and giant cell arteritis), while it is more common in medium to small vessels vasculitis (table 3), especially Kawasaki Disease, eosinophilic granulomatosis with polyangiitis (Churg-Strauss), and granulomatosis with polyangiitis [21-29].

Behçet syndrome — Pericarditis (either acute or recurrent) is a relatively rare manifestation of Behçet syndrome [30]. Behçet syndrome is a relapsing inflammatory disease with recurrent aphthous stomatitis, genital ulcerations, and uveitis as the most typical manifestations. Among the systemic vasculitides, Behçet syndrome is remarkable for its ability to involve blood vessels of all sizes (small, medium, and large) on both the arterial and venous sides of the circulation. Arterial disease is most commonly a small vessel vasculitis, but medium and large vessel disease may also develop. Perivascular and endovascular inflammation may lead to hemorrhage, stenosis, aneurysm formation, thrombus formation in both arteries and veins, and varices. On the contrary, atherosclerosis does not appear to occur at an accelerated rate in Behçet syndrome, as has been observed in other autoimmune diseases such as systemic lupus erythematosus. Symptomatic cardiac disease, such as aortic regurgitation, is possible in Behçet syndrome, although most manifestations are vascular. (See "Clinical manifestations and diagnosis of Behçet syndrome", section on 'Cardiac disease'.)

AUTOINFLAMMATORY DISEASES — As emerging causes of pericarditis, especially recurrent pericarditis, autoinflammatory diseases are characterized by a primary dysfunction of the immune system, mostly caused by mutations of genes involved in the regulation or activation of the inflammatory response without any apparent involvement of antigen-specific T cells or significant production of autoantibodies [31]. These disorders usually manifest in the pediatric population, with onset ranging from the first hours to the first decade of life. However, a limited number of patients experience disease onset during adulthood. The most common autoinflammatory syndromes are familial Mediterranean fever and tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS) [32-35].

Familial Mediterranean Fever — Familial Mediterranean Fever (FMF) is a disorder characterized by sporadic, paroxysmal attacks of fever and serosal inflammation. FMF is an autosomal recessive disease largely restricted to several ethnic groups originating in the Mediterranean region (Sephardic Jews, Armenians, Turks, North Africans, Arabs, and less commonly Greeks and Italians). However, the disease may be not restricted to these groups. In the United States, for example, FMF may be encountered in Ashkenazi Jews. Pericarditis, sometime recurrent but usually self-limiting, has been reported in patients with FMF [32,33]. (See "Clinical manifestations and diagnosis of familial Mediterranean fever".)

Tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS) — TRAPS, while rare, is the most common autosomal dominant autoinflammatory disorder and is caused by mutations in the TNFRSF1A gene encoding the 55-kD receptor for tumour necrosis factor-(TNF)-alpha. Particular hallmarks of TRAPS include the protracted duration of febrile attacks; rash, eye, and periorbital involvement in more than 80 percent of patients; and the nearly uniform presence of focal myalgias.

Recurrent pericarditis is a common feature of TRAPS, but it rarely occurs alone [34,35]. Familial clustering of pericarditis has been reported in 5 to 10 percent of TRAPS patients with recurrent pericarditis, thus suggesting in some cases a possible genetic predisposition [35]. Familial clustering, colchicine failure, and need of immunosuppressive therapies may represent clues for investigating mutations related to autoinflammatory diseases in these patients [34]. (See "Tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS)".)

SUMMARY AND RECOMMENDATIONS

Systemic autoimmune diseases, also known as systemic inflammatory diseases, are inflammatory syndromes involving at least two organ systems. Cardiac involvement (affecting the pericardium, myocardium, endocardium, and coronary arteries) is not uncommon in systemic inflammatory diseases, although major cardiac problems are not usually the presenting manifestation. (See 'Introduction' above.)

Pericardial involvement in seen in a variety of systemic inflammatory diseases, including systemic lupus erythematosus, rheumatoid arthritis, adult-onset Still's disease, systemic sclerosis, dermatomyositis, polymyositis, mixed connective tissue disease, Sjögren's disease, sarcoidosis, rheumatic fever, and the vasculitides. (See 'Specific systemic inflammatory diseases with pericardial involvement' above.)

The most common types of pericardial involvement with systemic inflammatory diseases are acute (or recurrent) pericarditis and asymptomatic pericardial effusions (table 3). While some patients may manifest with the typical signs and symptoms of pericarditis (fever, pleuritic chest pain) or a hemodynamically significant effusion (dyspnea, fatigue, hypotension), many are incidentally found to have pericardial involvement during other testing (electrocardiography, echocardiography, computed tomography of the chest). Rarely, constrictive pericarditis can develop due to marked inflammation of the pericardium. (See 'Clinical presentation, diagnosis, and treatment' above.)

The treatment approach to pericardial involvement in systemic inflammatory diseases is dependent on symptoms:

When a patient with pericardial involvement is asymptomatic, treatment is essentially that of the underlying systemic disease. (See 'Clinical presentation, diagnosis, and treatment' above.)

Patients with a hemodynamically significant pericardial effusion should have the fluid drained (eg, pericardiocentesis or pericardiotomy). (See "Pericardial effusion: Approach to management", section on 'Choice of pericardial drainage procedure'.)

Most patients with symptoms of acute pericarditis should be treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine (table 2). (See "Acute pericarditis: Treatment and prognosis", section on 'Treatment'.)

Two autoinflammatory diseases, Familial Mediterranean Fever and tumor necrosis factor receptor-1 associated periodic syndrome (TRAPS), are emerging causes of pericarditis, especially recurrent pericarditis. (See 'Autoinflammatory diseases' above.)

  1. Knockaert DC. Cardiac involvement in systemic inflammatory diseases. Eur Heart J 2007; 28:1797.
  2. Spodick DH. Pericardial disease in the vasculitis-connective tissue disease group. In: The Pericardium. A comprehensive textbook, Marcel Dekker, New York 1997. p.314-33.
  3. Imazio M, Spodick DH, Brucato A, et al. Controversial issues in the management of pericardial diseases. Circulation 2010; 121:916.
  4. Scardapane A, Brucato A, Chiarelli F, Breda L. Efficacy of an interleukin-1β receptor antagonist (anakinra) in idiopathic recurrent pericarditis. Pediatr Cardiol 2013; 34:1989.
  5. Vassilopoulos D, Lazaros G, Tsioufis C, et al. Successful treatment of adult patients with idiopathic recurrent pericarditis with an interleukin-1 receptor antagonist (anakinra). Int J Cardiol 2012; 160:66.
  6. Picco P, Brisca G, Traverso F, et al. Successful treatment of idiopathic recurrent pericarditis in children with interleukin-1beta receptor antagonist (anakinra): an unrecognized autoinflammatory disease? Arthritis Rheum 2009; 60:264.
  7. Langley RL, Treadwell EL. Cardiac tamponade and pericardial disorders in connective tissue diseases: case report and literature review. J Natl Med Assoc 1994; 86:149.
  8. Doria A, Iaccarino L, Sarzi-Puttini P, et al. Cardiac involvement in systemic lupus erythematosus. Lupus 2005; 14:683.
  9. Imazio M, Brucato A, Trinchero R, et al. Colchicine for pericarditis: hype or hope? Eur Heart J 2009; 30:532.
  10. Tincani A, Rebaioli CB, Taglietti M, Shoenfeld Y. Heart involvement in systemic lupus erythematosus, anti-phospholipid syndrome and neonatal lupus. Rheumatology (Oxford) 2006; 45 Suppl 4:iv8.
  11. Voskuyl AE. The heart and cardiovascular manifestations in rheumatoid arthritis. Rheumatology (Oxford) 2006; 45 Suppl 4:iv4.
  12. Efthimiou P, Paik PK, Bielory L. Diagnosis and management of adult onset Still's disease. Ann Rheum Dis 2006; 65:564.
  13. Parvez N, Carpenter JL. Cardiac tamponade in Still disease: a review of the literature. South Med J 2009; 102:832.
  14. Byers RJ, Marshall DA, Freemont AJ. Pericardial involvement in systemic sclerosis. Ann Rheum Dis 1997; 56:393.
  15. Meune C, Vignaux O, Kahan A, Allanore Y. Heart involvement in systemic sclerosis: evolving concept and diagnostic methodologies. Arch Cardiovasc Dis 2010; 103:46.
  16. Dalakas MC, Hohlfeld R. Polymyositis and dermatomyositis. Lancet 2003; 362:971.
  17. Bazzani C, Cavazzana I, Ceribelli A, et al. Cardiological features in idiopathic inflammatory myopathies. J Cardiovasc Med (Hagerstown) 2010; 11:906.
  18. Lundberg IE. Cardiac involvement in autoimmune myositis and mixed connective tissue disease. Lupus 2005; 14:708.
  19. Gyöngyösi M, Pokorny G, Jambrik Z, et al. Cardiac manifestations in primary Sjögren's syndrome. Ann Rheum Dis 1996; 55:450.
  20. Wyplosz B, Marijon E, Dougados J, Pouchot J. Sarcoidosis: an unusual cause of acute pericarditis. Acta Cardiol 2010; 65:83.
  21. Narita H, Ohte N, Yoneyama A, et al. Takayasu's arteritis accompanied with massive pericardial effusion--a case report. Angiology 1999; 50:421.
  22. Li JJ, Fang CH, Chen MZ, Chen X. Takayasu's arteritis accompanied with pericarditis: a case report. Cardiology 2004; 102:106.
  23. Guillaume M, Vachiery F, Cogan E. Pericarditis: an unusual manifestation of giant cell arteritis. Am J Med 1991; 91:662.
  24. Gonzalez-Gay MA, Martinez-Dubois C, Agudo M, et al. Giant cell arteritis: epidemiology, diagnosis, and management. Curr Rheumatol Rep 2010; 12:436.
  25. Blot M, Guépet H, Aubriot-Lorton MH, et al. An atypical case of giant cell arteritis (Horton's disease) associated with facial swelling, confusion, and pericarditis in an elderly woman. J Am Geriatr Soc 2010; 58:2040.
  26. Cullen S, Duff DF, Denham B, Ward OC. Cardiovascular manifestations in Kawasaki disease. Ir J Med Sci 1989; 158:253.
  27. Agard C, Rendu E, Leguern V, et al. Churg-Strauss syndrome revealed by granulomatous acute pericarditis: two case reports and a review of the literature. Semin Arthritis Rheum 2007; 36:386.
  28. Korantzopoulos P, Papaioannides D, Siogas K. The heart in Wegener's granulomatosis. Cardiology 2004; 102:7.
  29. Baldini C, Talarico R, Della Rossa A, Bombardieri S. Clinical manifestations and treatment of Churg-Strauss syndrome. Rheum Dis Clin North Am 2010; 36:527.
  30. Atzeni F, Sarzi-Puttini P, Doria A, et al. Behçet's disease and cardiovascular involvement. Lupus 2005; 14:723.
  31. Rigante D, Cantarini L, Imazio M, et al. Autoinflammatory diseases and cardiovascular manifestations. Ann Med 2011; 43:341.
  32. Kees S, Langevitz P, Zemer D, et al. Attacks of pericarditis as a manifestation of familial Mediterranean fever (FMF). QJM 1997; 90:643.
  33. Okutur K, Seber S, Oztekin E, et al. Recurrent pericarditis as the initial manifestation of Familial Mediterranean fever. Med Sci Monit 2008; 14:CS139.
  34. Cantarini L, Lucherini OM, Cimaz R, et al. Idiopathic recurrent pericarditis refractory to colchicine treatment can reveal tumor necrosis factor receptor-associated periodic syndrome. Int J Immunopathol Pharmacol 2009; 22:1051.
  35. Cantarini L, Lucherini OM, Baldari CT, et al. Familial clustering of recurrent pericarditis may disclose tumour necrosis factor receptor-associated periodic syndrome. Clin Exp Rheumatol 2010; 28:405.
Topic 16578 Version 19.0

References

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟