Rheumatoid pleuritis

Rheumatoid pleuritis, a form of pleural effusion, is an uncommon complication of rheumatoid arthritis, occurring in 2-3% of patients (Walker and Wright, 1967; Naylor, 1990) Rheumatoid pleura most often appears as an erythematous exanthema, discoloration, or gray discoloration and may grow into a tender, inflamed mass.

Rheumatoid patency is a nonspecific condition characterized by inflammation of the aorta or valve, so as to alter the blood-flow to the aortic valve. Rheumatoid patency typically occurs in older patients, and there is a significant risk for severe, late complications such as aortic valve stenosis, heart valve stenosis.

Presentation

Pleural effusion usually occurs in patients previously diagnosed with rheumatoid arthritis, but it can also occur concurrently with or before the development of the joint manifestations of the disease (Graham, 1990; Chou and Chang, 2002). Patients may present with the signs of pleural effusion: dullness on percussion, diminished or absent breath sounds and vocal fremitus, and egophony at the level of the pleural liquid.

Histopathology

Light microscopy reveals replacement of normal cells lining the pleura (mesothelial cells) by a layer of pseudostratified epithelioid cells, multinucleated giant macrophages, and necrotic material (Mandl et al., 1969; Lillington et al. 1971)

Diagnosis

Diagnosis relies on the characteristic cytopathology of the exudative pleural fluid, which contains elongated and giant multinucleated macrophages in a sea of amorphous granular material. The absence of mesothelial cells is also characteristic (Champion, 1968). While these findings are highly specific for rheumatoid pleuritis (Nosanchuk et al., 1968; Geisinger, 1985; Engel, 1986; Montes, 1988; Shinto, 1988), rheumatoid pleuritis must be considered if more than one of the above cytologic findings are detected.

Treatment

Steroids are the mainstay of treatment for rheumatoid arthritis, and have been shown to improve rheumatoid pleuritis.

References

• Champion GD, Robertson MR, Robinson RG (1968). "Rheumatoid pleurisy and pericarditis". Ann Rheum Dis. 27 (6): 521–30. doi:10.1136/ard.27.6.521. PMC 1010472. PMID 4178130.
• Chou CW, Chang SC (2002). "Pleuritis as a presenting manifestation of rheumatoid arthritis: diagnostic clues in pleural fluid cytology". Am J Med Sci. 323 (3): 158–61. doi:10.1097/00000441-200203000-00008. PMID 11908862.
• Engel U, Aru A, Francis D (1986). "Rheumatoid pleurisy. Specificity of cytological findings". Acta Pathol Microbiol Immunol Scand A. 94 (1): 53–6. PMID 3962679.
• Geisinger KR, Vance RP, Prater T, Semble E, Pisko EJ (1985). "Rheumatoid pleural effusion. A transmission and scanning electron microscopic evaluation". Acta Cytol. 29 (3): 239–47. PMID 3890439.
• Graham WR (1990). "Rheumatoid pleuritis". South Med J. 83 (8): 973–5. doi:10.1097/00007611-199008000-00030. PMID 2200144.
• Lillington GA, Carr DT, Mayne JG (1971). "Rheumatoid pleurisy with effusion". Arch Intern Med. 128 (5): 764–8. doi:10.1001/archinte.128.5.764. PMID 5119224.
• Mandl MA, Watson JI, Henderson JA, Wang N (1969). "Pleural fluid in rheumatoid pleuritis. Patient summary with histopathologic studies". Arch Intern Med. 124 (3): 373–6. doi:10.1001/archinte.124.3.373. PMID 4896636.
• Montes S, Guarda LA (1988). "Cytology of pleural effusions in rheumatoid arthritis". Diagnostic Cytopathology. 4 (1): 71–3. doi:10.1002/dc.2840040117. PMID 3378489.
• Naylor B (1990). "The pathognomonic cytologic picture of rheumatoid pleuritis. The 1989 Maurice Goldblatt Cytology award lecture". Acta Cytol. 34 (4): 465–73. PMID 2197838.
• Nosanchuk JS, Naylor B (1968). "A unique cytologic picture in pleural fluid from patients with rheumatoid arthritis". Am J Clin Pathol. 50 (3): 330–5. PMID 5676332.
• Shinto R, Prete P (1988). "Characteristic cytology in rheumatoid pleural effusion". Am J Med. 85 (4): 587–9. doi:10.1016/0002-9343(88)90665-1. PMID 3177420.
• Walker WC, Wright V (1967). "Rheumatoid pleuritis". Ann Rheum Dis. 26 (6): 467–74. doi:10.1136/ard.26.6.467. PMC 1010430. PMID 6066230.