Postgrad Med J: first published as 10.1136/pgmj.57.663.60 on 1 January 1981. Downloaded from

Postgraduate Medical Journal (January 1981) 57, 60-61

Arthropathy in Dressler's syndrome C. DAVIDSON M.B., M.R.C.P.

Birch Hill Hospital, Rochdale OL12 9QB

Summary prescribed. Five days later his sputum became puru- Three patients developed a polyarthritis in association lent and the chest X-ray showed cavitation in the with Dressier's (post-) syn- left mid zone. A penicillin-resistant Staphylococcus drome. Joint involvement was more pronounced in the pyogenes was isolated and the abscess slowly re- upper limbs and persisted many months after other solved on flucloxacillin. features of Dressler's syndrome had settled. In 2 cases Over the next 2 months the chest X-ray and WBC the findings in the joints were slight and might have returned to normal, and the steroids were tailed off. been overlooked but for the persistently raised ESR. However, he continued to have pain in his shoulders, There was a prompt symptomatic response to predni- hands, knees and ankles with 1-2 hr morning stiff- sone. ness and this more than all else prevented him from returning to work. There were few objective findings; Introduction some joint tenderness, pain at the extremes of move- The post-myocardial infarction syndrome de- ment and weak grip. There were no subcutaneous or scribed by Dressler (1956) is characterized by , tendon nodules; the ESR remained between 20-40 high ESR, , pneumonitis and . mm/hr but the rheumatoid factor, ANF and uriccopyright. Joint involvement has not previously been recog- acid were normal, and there were no joint erosions on nized in this syndrome, but was striking in the first X-ray. case described below. Two milder cases were sub- Eighteen months later he was admitted with acute sequently seen with similar features. inferior myocardial infarction, developed cardio- genic shock and died. At post-mortem he had an old Case 1 anterior and recent postero-septal infarct with a A 55-year-old man was admitted with an anterior large mural thrombus. There was fibrinous peri- myocardial infarct after a period of crescendo and adhesive pleurisy at the bases of both . Ten days later he developed fever, tachy- lungs. Unfortunately the joints were not examinedhttp://pmj.bmj.com/ cardia and a right pleural effusion. He was treated histologically. with digoxin and frusemide and anticoagulants were added a few days later when he developed ill-defined Case 2 calf tenderness. In the 3rd week he suddenly de- A 59-year-old man was admitted with an inferior veloped an inflammatory arthritis affecting shoul- myocardial infarction. He had a pericardial friction ders, elbows, wrists, knees and small joints of the rub, raised venous pressure and a gallop rhythm. hand. The metacarpophalangeal and interphalangeal The blood urea rose transiently to 41 8 mmol/l. He joints were visibly swollen and red, and the grip was given diuretics and prophylactic anticoagulants. on October 2, 2021 by guest. Protected weak. The white count rose to 19-8 x 109/l and the On the 5th day he developed purulent sputum and ESR to 68 mm/hr and there was a reversed albumin some shadowing in the right lower zone on chest X- globulin ratio (0 29: 0-31 g/l); rheumatoid and anti- ray. No organism was isolated but he received a nuclear factors were negative and serum uric acid course of amoxicillin. He continued to have a low was 0 41 mmol/l. The painful joints were treated with grade fever and on the 10th day the chest X-ray splinting and analgesics. showed a large pleural effusion on the right and a In the 4th week he developed haemoptysis and smaller one on the left. The pleural fluid was sterile the chest X-ray showed shadowing in the left mid but contained some polymorphs. His condition zone. No organism was isolated but the WBC rose slowly improved on an increased dose of frusemide to 27-4 x 109/l and the ESR to 110 mm/hr and amoxy- but the ESR rose to 88 mm/hr. He complained of cillin was given. In the 5th week a pericardial friction stiffness in both shoulders and there was restricted rub was heard and, with a belated diagnosis of movement, more on the left than the right. Dressler's syndrome, prednisolone 60 mg/day was Two weeks later he developed left pleuritic chest 0032-5473/81/0100-0060 $0.200 () 1981 The Fellowship of Postgraduate Medicine Postgrad Med J: first published as 10.1136/pgmj.57.663.60 on 1 January 1981. Downloaded from

Case reports 61 pain. The chest X-ray still showed small bilateral widespread joint involvement was present from the pleural effusions but the size was normal and outset, whereas in the milder cases pain was initially the ESR was 100 mm/hr. The pain settled quickly confined to the shoulders and later spread to other and anticoagulants and diuretics were tailed off. He joints. The symptoms persisted for several months continued to have pain in the shoulders and 3 months and the resulting disability seemed out of proportion later when he returned to work, he developed stiff- to the clinical findings. The temporal relation of the ness in the hands and knees, especially in the morn- arthropathy to the myocardial infarct, the rapid re- ings. He was tender over the metacarpophalangeal sponse to steroids and the lack of chronic sequelae joints, shoulder movements were restricted and suggests the arthropathy was part of Dressler's syn- small bilateral effusions were present in the knees. drome. The ESR was still raised at 54 mm/hr. Uric acid was Despite the numerous surveys and case reports of 0 45 mmol/l, rheumatoid factor negative and X- Dressler's syndrome joint involvement has only been rays of hands and feet normal. He was given predni- recorded once. Brock and Ofstad (1960) described sone 15 mg/day with dramatic improvement. Steroids 2 patients with a clinical picture suggesting atypical were gradually withdrawn over 6 months and now, Dressler's syndrome. One developed arthritis of the 2 years later, there has been no recurrence in his knee and elbow and one the knee alone; few clinical symptoms. details are given and the second may have had chon- drocalcinosis. In his own cases Dressier (1956) noted that pleuropericardial pain when present may radiate Case 3 to the arms or shoulder tip, but did not suggest that A 60-year-old man was admitted with an anterior the joints themselves were involved. myocardial infarct. He had a low grade fever from The pattern of joint involvement in the cases re- the 2nd to the 11th day post-infarction, associated ported here, affecting mainly shoulders and upper with pallor, malaise, stiffness in both shoulders and a limbs, is reminiscent of the shoulder-hand syndrome raised ESR (77 mm/hr). No pericardial friction rub following myocardial infarction (Edeiken, 1957). was heard and the chest X-ray remained clear. However, the clinical picture was of a polyarthro- Mobilization was slow with some continuing pains pathy and there was no swelling of the hands or later copyright. in his shoulders. Three months after the infarct he trophic change. There is a much closer similarity returned to work, but shortly afterwards developed between these cases and several patients described generalized 'rheumatism' with aching in the shoul- by Ernstene and Kinell (1939) in which transient ders and both arms. Chest X-ray at this time was 'rheumatoid arthritis' followed myocardial infarc- clear, but the ESR was 80 mm/hr. tion. Unfortunately there is not enough clinical in- Over the next month he deteriorated with involve- formation to know whether any of these might have ment of shoulders, knees, and the small joints of the had Dressler's syndrome. thumb and index finger on both hands. As a result The occurrence of joint symptoms in Dressler's his grip was poor, and considerable morning stiffness syndrome is not surprising in view of current opinion http://pmj.bmj.com/ was present. There was some tenderness of the affec- (Bernstein, 1977) which favours an auto-immune ted joints but no visible swelling or inflammation, no cause. The fact that these 3 cases were seen by one rheumatoid nodules, or tenosynovitis. For the first physician over a 3-year period suggests that joint time a soft pericardial rub was heard at the apex. involvement in Dressler's syndrome is not uncom- Full blood count, uric acid and immunoglobulins mon and has perhaps been overlooked. were normal, rheumatoid factor and antinuclear factor negative, but the ESR was 77 mm/hr. He was Acknowledgment given prednisolone 15 mg/day with resolution of I would like to thank Dr P. A. Bacon for his valuable on October 2, 2021 by guest. Protected his symptoms. Steroids were gradually withdrawn advice in writing this paper. over the next 6 months and his symptoms have re- curred to a milder degree. There are still few findings References BERNSTEIN, A. (1977) The post myocardial infarction syn- but the ESR has risen to 44 mm/hr. At present the drome of Dressier. British Journal of Hospital Medicine, arthralgia is controlled on anti-inflammatory drugs 17, 560. alone. BROCK, O.J. & OFSTAD, J. (1960) The post myocardial in- farction syndrome. Acta medica scandinavica, 166, 281. DRESSLER, W. (1956) A post-myocardial infarction syndrome. Journal of the American Medical Association, 160, 1379. Discussion EDEIKEN, J. (1957) Shoulder hand syndrome following myo- These cases have several features in common. cardial infarction with special reference to prognosis. Joint symptoms appeared soon after the myocardial Circulation, 16, 14. ERNSTENE, A.C. & KINELL, J. (1939) Pain in the shoulders as infarct at a time when there were other findings sug- a sequel to myocardial infarction. Archives of Internal gesting Dressler's syndrome. In the more severe case, Medicine, 66, 800.