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J R Soc Med. 2005 April; 98(4): 166–167.
PMCID: PMC1079443

Fibrinous peritonitis in a patient with rheumatoid arthritis

R Kapoor, BMSci BM BS,1 E Dean, MB BS,1 T Palferman, MB FRCP,2 and Z Khan, MRCP3

Ascites in rheumatoid arthritis has been linked to drug-induced liver damage but not previously to peritoneal disease.

CASE HISTORY

A man of 76, diagnosed 15 years ago with seropositive rheumatoid arthritis, had for 5 years been taking methotrexate as a disease-modifying agent (currently 7.5 mg per week). When he sought advice because of shortness of breath and abdominal distension the methotrexate was immediately stopped. On examination he had gross ascites. Constrictive pericarditis secondary to rheumatoid arthritis was excluded by cardiac MRI. Diagnostic peritoneal tap revealed an exudate and so the possibility of peritoneal disease was further investigated by laparoscopy, at which peritoneal and liver biopsies were obtained. The liver biopsy was normal but the peritoneal biopsy showed a fibrinous peritonitis with a mild chronic inflammatory infiltrate (Figure 1) similar to that seen in fibrinous pericarditis associated with rheumatoid arthritis.

Figure 1
Peritoneal biopsy specimen

Repeated drainage of the ascites was necessary after the patient's discharge from hospital, but after institution of prednisolone 15 mg daily there was no recurrence. The methotrexate was not reintroduced because the rheumatoid arthritis was well controlled.

COMMENT

An extensive search of the published work has yielded two reported cases of ascites related to rheumatoid arthritis.1,2 In these instances the aetiology was judged to be methotrexate-induced liver damage and the ascites resolved on withdrawal of the drug. The only other documented cause of fibrinous peritonitis is practolol, an extinct betablocker that our patient had never received.36 The fibrinous peritonitis in this patient was histologically very reminiscent of the constrictive pericarditis seen in rheumatological arthritis.

Acknowledgments

We thank Mrs Andrea Bradshaw for the digital imaging and photography and Dr J Sheffield for his guidance.

References

1. McRorie ER, Wright RA, Errington ML, Luqmani RA. Rheumatoid constrictive pericarditis. Br Rheumatol 1997;36: 100-3 [PubMed]
2. Clegg DO, Furst DE, Tolman KG, Pogue R. Acute, reversible hepatic failure associated with methotrexate treatment of rheumatoid arthritis. J Rheumatol 1989;16: 1123-6 [PubMed]
3. Kujala GA, Shamma'a JM, Chang WL, Brick JE. Hepatitis with bridging fibrosis and reversible hepatic insufficiency in a female with rheumatoid arthritis taking methotrexate. Arthritis Rheum 1990;33: 1037-41 [PubMed]
4. Gurry JF, Cunningham IG, Brooke BN. Betablockers and fibrinous peritonitis. BMJ 1975;ii: 498 [PMC free article] [PubMed]
5. Thompson RP, Jackson BT. Beta-blockers and fibrinous peritonitis. BMJ 1975;ii: 747 [PMC free article] [PubMed]
6. Allan D, Cade D. Delayed fibrinous peritonitis after practolol treatment. BMJ 1975;iv: 40 [PMC free article] [PubMed]
7. Windsor WO, Durrein F, Dyer NH. Fibrinous peritonitis: a complication of practolol therapy. BMJ 1975;ii: 68 [PMC free article] [PubMed]

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press