Aggressive Cholesterol Pericarditis With Minimal Effusion Masquerading as Treatment-Refractory Autoimmune Disease

A middle-aged woman with rheumatoid arthritis presented with treatment-refractory pericarditis. Symptoms persisted despite escalation of immunosuppression, and she had recurrent admissions for heart failure. Imaging revealed minimal pericardial effusion and a thickened pericardium. Invasive hemodynamics confirmed constrictive physiology, and a pericardiectomy was required. Pathology testing confirmed cholesterol pericarditis, a rare condition of inflammatory cholesterol deposits within the pericardium. Previous reports describe moderate-to-large volumes of gold-coloured pericardial fluid. This case illustrates that cholesterol pericarditis can present with minimal pericardial effusion and rapidly progress to pericardial constriction.