CHEARS

Case:

A 69-year-old man with no prior medical history presents over the course of several months with new-onset nonspecific joint pain and swelling without evidence of erosions. The joints involved include his wrists, elbows, hands, and knees.

He was initially treated for presumed gout but was unresponsive.

Laboratory findings include:

1. High-sensitivity C-reactive protein, 36 mg/L

2. White blood cell count, 13.0 x 103 /µL

3. Hemoglobin, 14 g/dL

4. Hematocrit, 45 g/dL

5. Thyroid stimulating hormone level, 1.13 U/mL

6. Serum creatinine, 0.8 mg/dL

7. Erythrocyte sedimentation rate, 19

8. Rheumatoid factor was positive

A 2-dimensional echocardiogram before starting immunomodulators was performed, showing a poorly visualized pericardial structure in the subcostal view that appeared to be compressing the right ventricle.

Although cardiomyopathy, heart failure, mitral valve disease, and amyloidosis are among 3 conditions seen in rheumatoid arthritis, pericarditis is the most common cardiac manifestation that occurs.

In general, echocardiographic evidence of pericarditis precedes and often occurs more often than clinically significant pericarditis. However, patients with clinical manifestations of pericarditis are at higher risk for mortality and progression to pericardial constriction.

What is the next best imaging modality to further evaluate the abnormal structure described here?

A.         Transesophageal echocardiogram

B.         Chest X-ray

C.         Chest computed tomography scan

D.         No further imaging is necessary

Please drop your answer in comment box with justification.