Rheumatoid pleuritis
| Rheumatoid pleuritis | |
|---|---|
| Fibrinous pleuritis overlying subpleural rheumatoid nodules (4864373998).jpg | |
| Fibrinous pleuritis overlying subpleural rheumatoid nodules
| |
| Symptoms | Chest pain, dyspnea, cough, fever, reduced breath sounds |
| Complications | Recurrent effusions, pleural thickening, fibrosis, empyema |
| Usual onset | Typically in patients with longstanding rheumatoid arthritis |
| Duration | Variable; may resolve or recur
|
| Causes | Complication of rheumatoid arthritis |
| Risk factors | Male sex, older age, high rheumatoid factor titers |
| Diagnosis | Pleural fluid analysis, chest X-ray, CT scan, pleural biopsy |
| Differential diagnosis | Tuberculosis, malignancy, lupus pleuritis, bacterial pneumonia |
| Prevention | Management of underlying rheumatoid arthritis |
| Treatment | Corticosteroids, NSAIDs, pleural drainage, immunosuppressive therapy |
| Medication | Prednisone, methotrexate, hydroxychloroquine |
| Prognosis | Good with treatment, though risk of recurrence exists |
| Frequency | Occurs in ~2–3% of patients with rheumatoid arthritis |
| Deaths | Rare; usually related to complications |
Rheumatoid pleuritis is a rare extra-articular manifestation of rheumatoid arthritis (RA), characterized by inflammation of the pleura resulting in a pleural effusion. It occurs in approximately 2–3% of individuals with established RA and is more common in middle-aged to elderly men with seropositive disease.
Clinical Presentation[edit]
Rheumatoid pleuritis may be asymptomatic or present with signs and symptoms of a pleural effusion, including:
- Pleuritic chest pain
- Dyspnea
- Nonproductive cough
- Fever
- Decreased breath sounds on auscultation
- Dullness to percussion
- Decreased or absent vocal fremitus
- Egophony at the upper fluid level
Pleural effusions may be unilateral or bilateral and are typically exudative.
Pathophysiology[edit]
The pathogenesis of rheumatoid pleuritis involves chronic inflammation of the pleural membrane, driven by autoimmune activity associated with RA. This leads to:
- Accumulation of pleural fluid
- Replacement of normal mesothelial cells by pseudostratified epithelioid cells
- Infiltration by multinucleated giant cells and macrophages
- Fibrinous and necrotic debris within the pleural space
Histopathology[edit]
Microscopic examination of pleural biopsy specimens reveals:
- Loss of the mesothelial cell layer
- Thickening of the pleura
- Pseudostratified epithelium-like lining composed of immune cells
- Presence of fibrin, necrotic tissue, and granulomatous inflammation
These features help distinguish rheumatoid pleuritis from other causes of pleuritis such as infection or malignancy.
Diagnosis[edit]
Diagnosis is based on clinical suspicion in a patient with RA and characteristic pleural fluid analysis findings:
- Pleural fluid is exudative (per Light's criteria)
- Low glucose concentration (<30 mg/dL)
- Low pH (<7.2)
- High lactate dehydrogenase (LDH)
- High rheumatoid factor titers
- Absence of mesothelial cells on cytology
- Presence of multinucleated giant cells and granular necrotic debris
Imaging such as chest X-ray or CT scan confirms the presence of pleural effusion.
Differential Diagnosis[edit]
Rheumatoid pleuritis must be distinguished from other causes of exudative pleural effusions, including:
- Tuberculous pleuritis
- Malignant pleural effusion
- Systemic lupus erythematosus (SLE)
- Parapneumonic effusion or empyema
Treatment[edit]
Management involves controlling the underlying RA and reducing inflammation:
- Corticosteroids (e.g., prednisone) are the mainstay of treatment
- Non-steroidal anti-inflammatory drugs (NSAIDs) may provide symptom relief
- Immunosuppressive agents such as methotrexate or hydroxychloroquine
- Therapeutic thoracentesis may be required for symptomatic relief in large effusions
- Pleurodesis or surgical intervention may be necessary in recurrent or complicated cases
Prognosis[edit]
With appropriate treatment, most patients recover without long-term sequelae. However, recurrent pleural effusions or development of chronic pleural thickening and fibrosis can occur. Rarely, complications such as empyema may develop.
