Rheumatoid Pleural Effusion

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Objectives

To describe the clinical and laboratory features of rheumatoid pleural effusion (RPE) and the diagnostic and therapeutic approaches to this condition.

Methods

The review is based on a MEDLINE (PubMed) search of the English literature from 1964 to 2005, using the keywords “rheumatoid arthritis” (RA), “pulmonary complication”, “pleural effusion”, and “empyema”.

Results

Pleural effusion is common in middle-aged men with RA and positive rheumatoid factor (RF). It has features of an exudate and a high RF titer. Underlying lung pathology is common. Generally RPE is small and resolves spontaneously but symptomatic RPE may require thoracocentesis. Rarely, RPE has features of a sterile empyematous exudate with high lipids and lactate dehydrogenase, and very low glucose and pH levels. This type of effusion eventually leads to fibrothorax and lung restriction. Superimposed infective empyema often complicates RPE. Oral, parenteral, and intrapleural corticosteroids, pleurodesis and decortication, have been used for the treatment of sterile RPE. Infected empyema is treated with drainage and antibiotics.

Conclusions

RPE may evolve into a sterile empyematous exudate with the development of fibrothorax. Symptomatic effusions or suspicion of other causes of exudate (infection, malignancy) require thoracocentesis. The “rheumatoid” nature of the pleural exudate in patients without arthritis mandates a pleural biopsy to exclude tuberculosis or malignancy. The optimal therapy of RPE has yet to be established. The role of cytokines in the course of RPE and the possible usefulness of cytokine blockade in the treatment of this RA complication require further evaluation.

Section snippets

Methods

This review is based on a MEDLINE (PubMed) search of the English literature from 1964 to 2005, using the keywords “rheumatoid arthritis,” “pulmonary complication,” “pleural effusion,” and “pleural empyema.” The search included studies concerning the diagnosis of rheumatoid pleural effusion (RPE), the usefulness of different diagnostic procedures, and treatment modalities. We reviewed 83 articles focused exclusively on pleural exudate in RA. As no randomized placebo-controlled studies have been

Epidemiology of RPE

The annual incidence of RPE in the RA population is 0.34% in women (157) and 1.54% in men (77) (10). It has been found in 9/1200 thoracoscopic biopsies (0.75%) performed for pleural effusion of different causes (11). Symptomatic pleural effusion has been described in 3 to 5% of RA patients, but pleural involvement on plain chest radiograms is much higher. Sequelae of pleurisy (pleural thickening and/or effusion) were found in 24% of men and 16% of women in 309 chest radiographs of RA patients (7

Discussion

Inflammatory pleural effusion is a common feature of RA, especially in a subgroup of middle-aged men with positive RF and a tendency to rheumatoid nodules. In most cases, RPE is small and asymptomatic, and there is no need for intervention. Large amounts of pleural fluid may compromise respiratory function and require aspiration to allow underlying lung expansion. Symptomatic or significant amounts of pleural effusion should be drained, preferably guided by US or CT. RPE has prominent signs of

Acknowledgment

The authors thank M. Perlmutter for help in the preparation of this article.

References (145)

  • A.J. Chandrasekhar et al.

    Antibody deposition in the pleuraa finding in drug induced lupus

    J Allergy Clin Immunol

    (1978)
  • J.T. Good et al.

    Lupus pleuritisclinical features and pleural fluids characteristics with special reference to pleural fluid antinuclear antibodies

    Chest

    (1983)
  • V. Khare et al.

    Antinuclear antibodies in pleural fluid

    Chest

    (1994)
  • S.E. Blomgren et al.

    Procainamide-induced lupus erythematosus

    Am J Med

    (1972)
  • P.R. Smith et al.

    Drug-induced lupus pleuritis mimicking pleural space infection

    Chest

    (1992)
  • U.B. Prakash

    Respiratory complications of mixed connective tissue disease

    Clin Chest Med

    (1998)
  • L.A. Hansen et al.

    Pulmonary lymphoma in Sjogren’s syndrome

    Mayo Clin Proc

    (1989)
  • A.M. Wolfe

    The epidemiology of rheumatoid arthritisa review

    Bull Rheum Dis

    (1968)
  • E.D. Harris

    Rheumatoid arthritis. Pathophysiology and implications for therapy

    N Engl J Med

    (1990)
  • W.C. Shiel et al.

    Pleuropulmonary manifestations of rheumatoid arthritis

    Semin Arthritis Rheum

    (1984)
  • D.A. White et al.

    Case Records of the Massachusetts General Hospital

    N Engl J Med

    (2001)
  • J.A. Talbott et al.

    Pulmonary involvement in rheumatoid arthritis

    JAMA

    (1964)
  • A.G. Juric et al.

    Prevalence of pulmonary involvement in rheumatoid arthritis and its relationship to some characteristics of the patients. A radiological and clinical study

    Scand J Rheumatol

    (1982)
  • W.C. Walker et al.

    Rheumatoid pleuritis

    Ann Rheum Dis

    (1967)
  • R.W. Light
  • A.G. Juric et al.

    Pleurisy in rheumatoid arthritis

    Scand J Rheumatol

    (1983)
  • P. Faurschou et al.

    Thoracoscopic, histological, and clinical findings in nine case rheumatoid pleural effusion

    Thorax

    (1985)
  • M. Hakala et al.

    Rheumatoid arthritis with pleural effusion includes a subgroup with autoimmune features and HLA-B8, Dw3 association

    Scand J Rheumatol

    (1986)
  • B. Knobel et al.

    Cholesterol pericarditis associated with rheumatoid arthritis

    Harefuah

    (2001)
  • J.F. Van Offel et al.

    Cholesterol crystals and IgE-containing immune complexes in rheumatoid pericarditis

    Clin Rheumatol

    (1991)
  • A.G. Juric et al.

    Pericarditis in rheumatoid arthritis. A clinical and radiological study

    Rheumatol Int

    (1986)
  • M. Abu-Shakra et al.

    Accelerated nodulosis, pleural effusion, and pericardial tamponade during methotrexate therapy

    J Rheumatol

    (1994)
  • C.A. Kelly et al.

    Chronic pericardial disease in patients with rheumatoid arthritis—a longitudinal study

    QJM

    (1990)
  • Y. Miyagawa et al.

    A case of steroid responding pneumonia in a patient with rheumatoid arthritis showing migratory infiltration and normal glucose levels in pleural effusions

    Br J Rheumatol

    (1993)
  • S. Baim et al.

    Rheumatoid arthritis, amyloidosis, and chylous effusions

    Arthritis Rheum

    (1979)
  • F.B. Smith et al.

    Localized pleural microdeposition of type A amyloid in a patient with rheumatoid pleuritis. Histologic distinction from pleural involvement in systemic amyloidosis

    Am J Clin Pathol

    (1993)
  • C.W. Chou et al.

    Pleuritis as a presenting manifestation of rheumatoid arthritisdiagnostic clues in pleural fluid cytology

    Am J Med Sci

    (2003)
  • W.R. Graham

    Rheumatoid pleuritis

    South Med J

    (1990)
  • J.T. Halla et al.

    Immune complexes and other laboratory features of pleural effusions

    Ann Intern Med

    (1980)
  • J.D. Pritkin et al.

    Respiratory failure due to a massive rheumatoid pleural effusion

    J Rheumatol

    (1990)
  • R.J. Anderson et al.

    Case records of the Massachusetts General Hospital

    N Engl J Med

    (1994)
  • M.L. Russell et al.

    Rheumatoid pleural effusionlack of response to intrapleural corticosteroid

    J Rheumatol

    (1986)
  • P.A. Dieppe

    Empyema in rheumatoid arthritis

    Ann Rheum Dis

    (1975)
  • G.A. Lillington et al.

    Rheumatoid pleurisy with effusion

    Arch Intern Med

    (1971)
  • D.P. Naidich et al.

    The pleura and chest wall

  • P.C. Yang et al.

    Value of sonography in determining the nature of pleural effusionanalysis of 320 cases

    AJR Am J Roentgenol

    (1992)
  • R.G. Wu et al.

    Image comparison of real-time gray-scale ultrasound and color Doppler ultrasound for use in diagnosis of minimal pleural effusion

    Am J Respir Crit Care Med

    (1994)
  • T.C. McLoud et al.

    Imaging the pleurasonography, CT, and MRI imaging

    AJR Am J Roentgenol

    (1991)
  • L.A. Robinson et al.

    Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas

    Ann Thorac Surg

    (1994)
  • T.C. McLoud

    CT and MRI in pleural disease

    Clinics in chest medicineDis Pleura

    (1998)
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