INTRODUCTION: Pneumonia, cancer, tuberculosis, and pulmonary embolism account for most exudative effusions. Rhematoid pleuritis usually occurs during the course of previously diagnosed rheumatoid arthritis. Occasionally, it may be first manifestation of the disease.
CASE PRESENTATION: A 22-year-old man was admitted to our hospital because of persistent bilateral pleural effusions and new onset of fever. He had been diagnosed with tuberculosis pleurisy in another hospital (all ARB smears were negative from pleural effusion at that time) 2 months ago and had been receiving anti-tbc drug therapy since than. He has begun to experience fever, general malaise and chest pain aggravated by cough for 3 days. Thoracentesis was performed. Cytologic examination of pleural fluid revealed no malignant cells. Given an effusion with predominance of neutrophils and high lactade dehydrogenase level, empyema was suspected and the patient was treated accordingly antibiotics. Microbiologic studies including smears and cultures of pleural fluid showed no yields. Meantime a rash occurred over his body. Pleural biopsy though video-assisted thoracoscopic surgery (VATS) was performed and demonstrated the characteristic histopathologic findings of Still‘s disease. Methylprednisolone, methotrexate, and other immunosuppressives were started. His fever disappeared and pleural effusion regressed.
DISCUSSIONS: Although pleural effusion is the most common intrathoracic complication of rheumatoid arthritis, it occurs only 2 to 3 % of patients. Occasionally, it may be the first manifestation or coincide with the onset of the disease. Adult onset of Still‘s disease (juvenile rheumatoid arthritis with septic appearance) is rare, leading to clinical signs similar to those seen in bacterial sepsis, lymphomas, or systemic autoimmune diseases. This disease can present with fever and can cause difficulties in the diagnosis. Rheumatoid pleural effusion is described as an exudate with low values of glucose and pH and high LDH activity. However, this biochemical constellation is suggestive but not specific of rheumatoid pleuritis, it can be found in the effusions caused by malignancy, complicated parapneumonic effusions, empyema, and tuberculosis. Accordingly, a high index of suspicion is of clinical importance in making a diagnosis. The diagnosis is based upon the evaluation of clinical signs and laboratorical data together. Prolonged immunosuppressive therapy is required.
CONCLUSION: This case illustrates that rheumatoid pleuritis should be suspected in a patient with exudative pleural effusion who doesn't respond to antibiotics. A high index of suspicion is of clinical importance in making a diagnosis.
DISCLOSURE: Sevin Baser, None.