Bilateral pneumothoraces caused by subpleural rheumatoid nodules in malignant rheumatoid arthritis

Abstract

A case of bilateral pneumothoraces caused by subpleural rheumatoid nodules in malignant rheumatoid arthritis (RA) is reported. A 56-year-old man with a long history of RA was admitted to another hospital in February 1984 because of high fever, progressive arthritis, cough and sputa. Chest X-ray film disclosed bilateral pleural effusions and a coin lesion in the left lung field. He had no history of occupational exposure to dust. The white-cell count was 13, 600, the erythrocyte sedimentation rate 63mm per hour, CRP 9+, CH50 23U/ml and RAHA 1:160. He was initially treated with prednisolone 30mg/day and antituberculosis drugs, but experienced little improvement. Prednisolone was increased to 60mg/day and the patient became afebrile. He was transferred to this hospital in April 1984.He had active polyarthritis (classical RA, stage IV, class III), but no subcutaneous nodules. Thoracentesis yielded a greenish yellow effusion with protein 17.6g/dl, glucose 0mg/d1 and cell count 970/mm3 (neutrophils 48%, histiocytes 16%, lymphocytes 35%). Cultures for tuberculosis were negative and cytologic examinations showed no atypical cells. The echocardiogram disclosed a pericardial effusion. Chest X-ray film revealed bilateral pneumothoraces and pleural effusions, and a coin lesion in the left lung. Computed tomography of the chest revealed bilateral pleural effusions and pleural thickening and a subpleural tumor in the left lung. In addition, he had episcleritis and peripheral neuropathy in the right leg. He was diagnosed as malignant RA. He was treated with chest tube drainage without improvement. In September, the right thoracotomy with decortication and abrasion was performed. Several yellow, subpleural nodules were observed. Histological examination of the nodule disclosed infiltration of histiocytes and lymphocytes, and giant cells around necrosis or cavity, but typical “palisading arrangement” was not found. The fluorescent staining for tubercle bacilli was negative. In this case, the pneumothorax was most probably caused by cavitation and rupture of subpleural rheumatoid nodules.Pneumothorax is an unusual complication in the pleuropulmonary manifestations of RA and so far no case has been reported in Japan.