Pleural disease preceding arthralgia occurs in < 7% of patients with rheumatoid pleuritis. Bilateral pleural effusions are infrequent and massive pleural effusions are rare. We describe a case with the aforementioned features, confirmed by pathognomonic cytologic findings to be rheumatoid pleuritis.
A 56 year-old alcoholic male presented with progressive dyspnea and cough. Physical exam revealed a febrile, tachycardic, unkempt male with poor dentition, left-sided diminished breath sounds, percussion dullness, and normal musculoskeletal exam. Chest radiograph confirmed a massive left pleural effusion. Pleural fluid analysis disclosed pH 7.18, glucose < 10 mg/dl, LDH 3273 IU/L, total protein 4.9 g/dL, WBC 930,000 with 68% neutrophils, negative gram stain, and severe acute inflammation without malignancy on cytology. Closed tube thoracostomy was performed. Despite ceftriaxone and clindamycin, fever persisted with development of diffuse arthralgia. Chest computed tomography (CT) confirmed left pleural fluid evacuation, small right pleural effusion, and cavitary subpleural nodule. Right pleural fluid resembled left-sided fluid upon laboratory evaluation. Pleural fluid Rheumatoid Factor (RF) was 160 IU/ml and serum RF 320 IU/ml. Cultures remained negative. Cytologic review of pleural fluid samples revealed the diagnostic triad: elongated macrophages, giant multinucleated macrophages, and background of granular necrotic debris. Daily oral prednisone 40 mg resulted in resolution of pleuritis and arthralgias.DISCUSSION: Atypical presentation and aspiration pneumonia risk factors lead to initial treatment for complicated parapneumonic effusion. Lack of improvement after pleural fluid drainage and antibiotics, onset of arthralgias, and subpleural nodule on CT shifted our focus toward rheumatoid pleuritis. Although no diagnostic pleural to serum RF ratio exists, the cytologic pathognomonic triad for rheumatoid pleuritis established the diagnosis.
When rheumatoid pleuritis is suspected, the cytopathologist should be alerted to search for the diagnostic triad.
F.R. Quijano, None.