SESSION TITLE: Pleural Disease Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Black pleural effusion is an extremely rare entity and is seldom encountered. Previous case reports have identified atypical infections, malignancy and hemorrhage as possible etiologies. We report a novel case of black pleural effusion secondary to rheumatoid pleurisy which preceeded the onset of arthritic symptoms
CASE PRESENTATION: A 38-year-old man presented with dyspnea, tachypnea and right chest pain for 3 weeks. On examination he was tachypneic with otherwise normal vitals. Air entry was absent over majority of the right lung fields. Other systemic examination was normal. Laboratory investigation showed normocytic anemia(Hemoglobin - 10.4), normal leukocyte count, increased erythrocyte sedimentation rate(68mm/hr) and C-reactive protein(0.7mg/dl). Chest radiography demonstrated a large right sided pleural effusion. Computerised tomography confirmed the presence of effusion with mild pleural thickening, right lung atelectasis and no evidence of underlying lung pathology. Thoracentesis demonstrated grossly black pleural effusion with an elevated red blood cell count(240,000), normal white count(480) with 60% neutrophils,28% lymphocytes, low glucose levels(25 mg/dl), elevated LDH levels(3698 units/l), protein level(4.5 mg/dl), normal cholesterol levels(170 mg/dl), low pH(7.24) and low adenosine deaminase levels(16 units/l). Serum protein level and lactate dehydrogenase levels were 6.8 and 220 units/l respectively. Pleural fluid cultures and tuberculin skin test were negative. No clinical or imaging evidence of pancreatic, hepatic or subdiaphragmatic pathology were identified. Given suspicion for autoimmune disease pleural fluid rheumatoid factor and antinuclear antibody were sent of which rheumatoid factor was positive. Additional laboratory data showed increased serum levels of anti-cyclical citrullinated peptide and rheumatoid factor. Chest radiography following multiple thoracentesis showed lack of lung expansion prompting surgical decortication and pleural biopsy which demonstrated marked collagenization, organizing granulation tissue, cholesterol granuloma and fibrin clots. Microbiological smears, cultures, cytology of pleural fluid and tissue were negative. At this point his biochemical and biopsy findings were suggestive of rheumatoid pleurisy and low dose prednisone therapy was started. Good clinical response was noted with resolution of fluid collection within 4 weeks. At follow-up visit 3 months later he reported having polyarthraligias and was diagnosed to have rheumatoid arthiritis as per criteria.
DISCUSSION: Pleural effusions accompany around 5% cases of known rheumatoid arthritis and can occur before, along with or after the development of joint symptoms1. Absence of arthritis symptoms can delay the diagnosis of rheumatoid pleurisy thus delaying treament and prompting extensive workup. Rheumatoid pleurisy causes an exudative effusion with low glucose, low pH and high lactate dehydrogenase levels2 as in our case. However, this biochemical constellation is only suggestive of and not specific to rheumatoid pleurisy. Black pleural effusion can occur in relation to infection with aspergillus, malignant melanoma or secondary to hemorrhage and hemolysis associated with lung cancer. In our patient the effusion was black most likely secondary to hemolysis. In most cases the effusions associated with rheumatoid pleurisy are asymptomatic and do not require any form of therapy. Symptomatic effusions, presence of pleural thickening, persistence of effusion or absence of lung expansion in response to thoracentesis necessitate decortication. Steroid therapy has shown benefit in some patients as in our case3 however is not recommended for asymptomatic patients.
CONCLUSIONS: Autoimmune disorders can often manifest as isolated pleural effusion respresenting a diagnostic dilemma. Rheumatoid pleurisy can preceede joint symptoms. Effusions with extensive hemolysis can present as black pleural effusion. Complicated rheumatoid pleurisy may require decortication followed by steroid therapy as in our case. This case is novel with regards to rheumatoid pleurisy presenting as black pleural effusion
Reference #1: Walker W et al.Pulmonary lesions and rheumatoid arthritis.Medicine 1968;47:501
Reference #2: Halla J et al.Immune complexes and other laboratory features of pleural effusions: a comparison of rheumatoid arthritis, systemic lupus erythematosus, and other diseases.Ann Intern Med 1980;92:742
Reference #3: Bouros D et al. Pleural involvement in systemic autoimmune disorders.Respiration 2008;75:361
DISCLOSURE: The following authors have nothing to disclose: Amith George Jacob, Amrutha Mary George, Teny John
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