Ann Thorac Surg 2005;80:1519-1521
© 2005 The Society of Thoracic Surgeons
Case report
Rheumatoid Pleural Effusion in the Absence of Arthritic Disease
James S. Allan, MD
*
,
Dean M. Donahue, MD,
Julie M. Garrity, RN
Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Accepted for publication April 12, 2004.
* Address reprint requests to Dr Allan, Massachusetts General Hospital, 55 Fruit St, Blake 1570, Boston, MA02114 (Email: jallan{at}partners.org).
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Abstract
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Rheumatoid pleural effusion is an unusual complication of rheumatoid disease that typically presents subsequent to other more common manifestations of rheumatoid illness. The case of a 72-year-old woman with a rheumatoid pleural effusion is discussed. The patient presented with dyspnea, but without any history of rheumatoid arthritis. The patient was treated by thoracentesis, followed by video-thoracoscopy and pulmonary decortication. Postoperatively, the patient's effusion partially reaccumulated. Steroid therapy resulted in prompt and permanent resolution of the effusion. The patient remains asymptomatic 1 year after her presentation. The biochemical, serologic, and cytologic characteristics of rheumatoid effusions are reviewed.
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Introduction
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Inflammatory pleural effusions are an uncommon complication seen in about 2% to 5% of patients with rheumatoid arthritis [1–4]. They typically occur during the evolution of established rheumatoid arthritis, but occasionally they are seen contemporaneously with the onset of arthritic symptoms. Rheumatoid effusions are seldom seen in the absence of arthritic disease. We report the case of a 72-year-old woman whose rheumatoid effusion presented in the absence of arthritic disease.
A 72-year-old woman with a past medical history remarkable only for an appendectomy presented with shortness of breath and a sharp, pleuritic pain localized to the left lower chest wall with radiation to the left shoulder. The patient gave no history of arthritis or other manifestations of rheumatoid disease. An electrocardiogram was normal, as were serum troponin and ß-natriuretic peptide levels. The initial chest roentgenogram showed a large left-pleural effusion with marked atelectasis of the left lower lobe (Fig 1). A computed tomographic scan confirmed the presence of a large, left pleural effusion with compressive atelectasis of the left lower lobe (Fig 2). A small amount of bi-apical scarring was also noted. No lung masses were identified.
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Fig 2. Chest computed tomographic scan showing a large left pleural effusion with compressive atelectasis of the left lower lobe.
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A thoracentesis showed an exudative effusion with a white blood cell count of 125 per µL (55% polymorphonuclear leukocytes, 45% monocytes), lactic acid dehydrogenase of 1,652 U/L, total protein of 5.8 g/dL, a pH of 7.01, and a glucose level of 7 mg/dL. Gram stains and acid-fast stains of the pleural fluid were negative. Cytologic examination showed large numbers of acute inflammatory cells without evidence for malignancy. A postthoracentesis chest roentgenogram showed a replacement pneumothorax without any reexpansion of the left lower lobe.
Given the possibility of an empyema, the failure of the left lower lobe to reexpand, and the patient's persistent shortness of breath, video thoracoscopy was performed on hospital day 5. The left lower lobe was encased in a dense inflammatory rind. Pulmonary decortication was therefore performed through a muscle-sparing thoracotomy. Again, pleural fluid cytology showed acute inflammatory cells with no evidence of malignancy, and microbiologic studies were negative. No epithelioid cells were seen.
Consultation with a rheumatologist was obtained; however, no other symptoms or physical signs of rheumatologic disease were identified. A semiquantitative serum rheumatoid factor was positive at 160 IU/mL, and an antinuclear antibody titer was 1:40 with a homogenous, specked pattern. A serum antineutrophil cytoplasm antibody test was negative, and enzyme-linked immunosorbent assays for antip29 and antimyeloperoxidase antibodies were also negative. A tuberculin skin test was nonreactive, as was a Candida antigen control. A mumps control showed mild induration. No immunosuppressive or antiinflammatory therapy was recommended. The patient was discharged home with significant symptomatic improvement on postoperative day 6.
The patient returned to the hospital 10 days after discharge, again complaining of shortness of breath. Radiographic evaluation showed that the left-sided pleural effusion had recurred. In addition, a small right-sided effusion had also developed. Tube thoracostomy was performed on the left side. Pleural fluid analysis again showed an exudative effusion (white blood cell count was 1,100 per µL [90% polymorphonuclear leukocytes, 8% lymphocytes]; lactic acid dehydrogenase was 562 U/L; and total protein was 4.5 g/dL) with a pH of 6.84 and a glucose level of 6 mg/dL. A plural fluid rheumatoid factor level was 160 IU/mL, and the C4 complement level on the fluid was less than 0.04 g/L. Oral steroid therapy with 20 mg of daily prednisone was initiated, and the patient was discharged home on hospital day 6 after chest tube removal.
At the patient's 1 year follow-up, she remains well without arthritic symptoms with prednisone (5 mg/day). Her pleural effusions have not recurred.
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Comment
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The recognition that rheumatoid arthritis is a systemic disease with protean manifestations was first advanced by Fuller [5] in 1860, although little attention was paid to this observation until Baggenstoss and Rosenberg [6] published a postmortem examination series in 1943 that chronicled a wide variety of extra-articular lesions associated with rheumatoid arthritis. In the 20 years that followed, rheumatoid pleural effusion became a well-established clinical diagnosis.
Although the absolute incidence of rheumatoid pleural effusion is low, rheumatoid effusions are one of the more common pulmonary manifestations of rheumatoid arthritis [7]. Although rheumatoid arthritis itself has a female predominance, approximately three quarters of all rheumatoid pleural effusions are found in men who have reached their sixth decade of life [7–10]. These effusions are typically unilateral, but as in the case of this patient, bilateral effusions may also be seen [8, 11]. The time course of rheumatoid effusions is extremely variable [7, 11].
The rheumatoid effusion is an exudative effusion, typically containing numerous polymorphonuclear leukocytes at the time of presentation, as seen in this case. However, as the effusion matures, a lymphocytic predominance is sometimes observed [12].
The next common finding in rheumatoid effusions is a low pleural fluid glucose level, usually less than 30 mg/dL [8]. It has been postulated that a selective blockade in glucose transfer from the blood to the pleural space is responsible for this finding [13].
The rheumatoid effusion also has a characteristically low pH, typically between 7.00 and 7.13 [9, 12]. However, it is not unusual to see a pH less than 7.00, as in this case. It has been similarly proposed that this low pH is due to an impairment of the transfer of acidic anaerobic metabolites across an inflamed pleura.
The combination of a polymorphonuclear exudate along with a low pleural fluid glucose and pH makes the distinction between rheumatoid effusions and empyema difficult. This is particularly true for the tuberculous empyema, because mycobacterial organisms are fastidious to culture and are not often recovered on an acid-fast stain. However, there are several findings that can assist the clinician in making this distinction. First, the finding of an elevated pleural fluid rheumatoid factor (titers >1:320 or semiquantitative levels >80 IU/mL) is fairly typical, although not specific for this condition. Second, rheumatoid effusions typically have low C4 complement levels (<0.03 g/L), which stand in strong contradistinction to C4 levels in tuberculous and malignant effusions that are 10-fold higher on average [9]. Third, pleural fluid cytology will occasionally show a characteristic epithelioid cell similar to cells seen in rheumatoid synovitis [14]. This finding is quite specific when present.
This case illustrates an unusual presentation of a rheumatoid pleural effusion and demonstrates the utility of a comprehensive clinical and laboratory evaluation in recognition of these uncommon effusions.
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References
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- Naylor B. The pathognomonic cytologic picture of rheumatoid pleuritis Acta Cytol 1990;34:465-473.[Medline]
- Walker WC, Wright V. Rheumatoid pleuritis Ann Rheum Dis 1967;26:467-474.[Free Full Text]
- Joseph J, Sahn SA. Connective tissue diseases and the pleura Chest 1993;104:262-270.[Free Full Text]
- Helmers R, Galvin J, Hunninghake GW. Pulmonary manifestations associated with rheumatoid arthritis Chest 1991;100:235-238.[Free Full Text]
- Fuller HW. Rheumatism, rheumatic gout, and sciaticatheir pathology, symptoms, and treatment. 3rd ed. London: J & A, Chuchill, Ltd; 1860.
- Baggenstoss AH, Rosenberg EF. Visceral lesions associated with chronic infectious (rheumatoid) arthritis Arch Path 1943;35:503.
- Walker WC, Wright V. Pulmonary lesions and rheumatoid arthritis Medicine (Baltimore) 1968;47:501-520.[Medline]
- Lillington GA, Carr DT, Mayne JG. Pleurisy with effusion in rheumatoid arthritis with reference to the low concentration of glucose in pleural fluid Am Rev Respir Dis 1962;85:345-350.[Medline]
- Petterson T, Klockars M, Hellstrom PE. Chemical and immunological features of pleural effusionscomparison between rheumatoid arthritis and other diseases. Thorax 1982;37:354-361.[Abstract/Free Full Text]
- Halla JT, Schrohenloher RE, Volanakis JE. Immune complexes and other laboratory features of pleural effusionsa comparison of rheumatoid arthritis, systemic lupus ery-thematosus, and other diseases. Ann Intern Med 1980;92:748-752.
- Carr DT, Mayne JG. Pleurisy with effusion in rheumatoid arthritis with reference to the low concentration of glucose in pleural fluid Am Rev Respir Dis 1962;85:345-350.
- Sahn SA, Kaplan RL, Maulitz RM, Good Jr JT. Rheumatoid pleurisyobservation on the development of low pleural fluid pH and glucose level. Am J Respir Crit Care Med 1980;140:1237-1238.
- Dodson WH, Hollingsworth JW. Pleural effusion in rheumatoid arthritisimpaired transport of glucose. N Engl J Med 1966;275:1337-1342.
- Chou C, Chang S. Pleuritis as a presenting manifestation of rheumatoid arthritisdiagnostic clues in pleural fluid cytology. Am J Med Sci 2002;323:158-161.[Medline]
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Abstract
Introduction
