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A 45-year-old man with recurrent pleural effusion was admitted to the hospital with acute respiratory failure due to a massive pleural effusion on the left. A comprehensive diagnostic examination showed that pleural effusion had a rheumatoid etiology. Thoracocentesis was performed and treatment with prednisone and methotrexate was prescribed. This led to the elimination of pleural effusion without subsequent relapses.
What is the most likely diagnosis based on the description of the clinical case?
Clinical pleural effusion is observed rarely in rheumatoid arthritis, in approximately 2–5% of cases, usually with prolonged active illness 1 .
The patient denied the presence of cough, fever and night sweats; he had a history of left-sided thoracocentesis two weeks ago. In addition, over the past year, the patient has lost 20 pounds. He noted no pain or swelling of the joints. A history of smoking 20 packs of years.
Deviations of the main vital signs included a respiratory rate of 40 per minute and tachycardia with a frequency of 120 beats / min. Body temperature was 98.6 ° F; no jugular vein expansion was observed. Examination of the chest revealed a dull sound in the left half of the chest with a weakening of respiratory sounds. Examination of the cardiovascular system and abdominal cavity without features, joint swelling was not observed. Rheumatoid nodules were absent.
Initial laboratory tests showed the presence of sinus tachycardia and a triple negative serum troponin level. The hematocrit was 30%, the number of leukocytes was 7.9 * 10 ^ 9 / l. A chest x-ray showed a large volume pleural effusion in the left pleural cavity. The patient underwent emergency thoracocentesis and installed a drainage tube into the pleural cavity. The pleural effusion was bloody and contained 4,000 cells per ml (45% neutrophils, 40% lymphocytes, 15% eosinophils). The level of lactate dehydrogenase (LDH) is 1253 U / l, total protein 5.5 g / dl and glucose 15 mg / dl. Gram staining and analysis of acid-resistant bacteria strains were negative. A cytological examination of pleural effusion showed the presence of cells of acute inflammation without signs of malignant neoplasm.
In order to determine the possible cause of recurrent left-sided pleural effusion, a pleural biopsy and pleurodesis were performed on the left side. A pleural biopsy showed fibrous connective tissue lined with mesothelium without signs of malignancy, and the patient was discharged from the hospital with antibiotic therapy.
Ten days later, the patient was hospitalized again with the same symptoms, namely shortness of breath and pain in the left half of the chest. A chest x-ray showed a repeated massive pleural effusion on the left. Thoracocentesis was performed on the patient; effusion analysis showed an LDH of 1040, glucose of 12 mg / dl and a protein of 5.3 g / dl. 250) This time, a pleural effusion of rheumatoid etiology was diagnosed and treatment with prednisone and methotrexate was started. At the time of the follow-up examination, after 1 year, there were no signs of arthritis, and there was no relapse of pleural effusion. Currently, the patient is receiving maintenance therapy with prednisone and methotrexate for oral administration.
Pleural effusion with rheumatoid arthritis is most often found in patients with a prolonged active inflammatory process in the joints and rheumatoid nodules 6 . Massive pleural effusion is rarely the main manifestation of RA, and in the absence of symptoms of arthritis, diagnosis is difficult. Characteristically raising (unclear) in serum (in our case, this index was not measured) and the reduction of the complement components C3 and C4 7. Normally, the predominant cells are lymphocytes, but neutrophilia can also be observed. This case demonstrates the difficulties in diagnosing rheumatoid arthritis in a patient with seronegative rheumatoid factor, without symptoms of arthritis, with the main manifestation of rheumatoid arthritis in the form of a massive recurrent pleural effusion, accompanied by acute respiratory failure. A distinctive feature of this clinical case is a pronounced clinical picture without concomitant arthritis. Seropositive rheumatoid factor is determined in 95% of patients with pleural effusion associated with RA 8. In our case, the analysis of rheumatoid factor in the pleural fluid was not carried out. Another unique feature of this clinical case is pleural fluid eosinophilia, which is rare 8 . The final diagnosis was made on the basis of the characteristic features of pleural fluid (low glucose, high LDH) after the exclusion of infection and malignant neoplasms, taking into account the high titer of antibodies to CCP. Moreover, the answer to prednisone and methotrexate with the complete elimination of pleural effusion without subsequent relapses spoke in support of the diagnosis.
With a small and asymptomatic pleural effusion of rheumatoid etiology, treatment is not required. Most cases resolve spontaneously or with rheumatoid arthritis 9 . In the case of an extensive and clinically pronounced pleural effusion, NSAIDs are treated, repeated thoracocentesis, oral administration and intrapleural administration of steroid drugs. These treatments are not always effective, and rheumatoid arthritis treatment 9 is most beneficial . With refractory pleural effusion, pleurodesis 9 may be considered . In the case of severe thickening of the pleura and compression of the lung, lung decortication may be required 1.9 .
Rheumatoid pleurisy should be borne in mind when conducting differential diagnosis of unexplained pleural effusion even in the absence of arthritis and with seronegative rheumatoid factor. This will help to make a timely diagnosis, start appropriate treatment and prevent complications that may occur with a delay in diagnosis or making an erroneous diagnosis.
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