Spontaneous pneumothorax: an unusual presentation of rheumatoid arthritis

S. Saravana, T. Gillott, F. Abourawi1, M. Peters2, A. Campbell3 and S. Griffith4

Department of Rheumatology, Department of Endocrinology and Department of Pathology, Diana Princess of Wales Hospital, Grimsby DN33 2BA, UK, Department of Cellular Pathology, Hull Royal Infirmary, Hull, UK and Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK

Correspondence to: S. Saravana, Department of Rheumatology, Diana Princess of Wales Hospital, Grimsby DN33 2BA, UK. E-mail: adersh555saravana{at}hotmail.com

SIR, We read with interest the article by Gotsman et al. [1] describing a case of spontaneous pneumothorax in a rheumatoid arthritis (RA) patient treated with methotrexate. Spontaneous pneumothorax secondary to pulmonary rheumatoid nodules is an uncommon complication of RA. Cases described so far have been male patients with longstanding RA [2]. We describe a female patient who developed a spontaneous right-sided pneumothorax before developing arthritic symptoms.

A 40-yr-old lady developed dyspnoea on minimal exertion following a heavy cold. She also complained of right-sided pleuritic chest pain radiating to her back. There was no significant past medical history and she was not taking any medication. She worked as a cook in a residential home and was a smoker of 5 cigarettes per day. On examination, she was found to have clinical features of a right-sided pneumothorax, which was confirmed by chest X-ray (Fig. 1). The eosinophil count was slightly raised at 0.6 x 109/l (normal range 0.04–0.4 x 109/l); the full blood count, liver function tests and urea and electrolytes were unremarkable. The pneumothorax failed to resolve with needle aspiration and chest tube insertion. Subsequently she underwent right sided video assisted thoracoscopic surgery (R VATS) apical bullectomy, apical pleurectomy and pleural abrasion. She made an uneventful recovery. The histology of the excised tissue showed granulomatous pleural inflammation, fibrinous exudate, palisading histiocytes and scattered multinucleated giant cells consistent with a rheumatoid nodule (Fig. 2). Staining for acid fast Bacilli (AFB) was negative.



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FIG. 1. Histology of the excised tissue showed granulomatous pleural inflammation, fibrinous exudate, palisading histiocytes and scattered multinucleated giant cells, consistent with a rheumatoid nodule.

 


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FIG. 2. Chest X-ray showing right-sided pneumothorax.

 
One week after surgery, the patient developed acute onset of pain and swelling in her left knee and the small joints of her hands. She also complained of painful feet and early-morning stiffness lasting more than 30 min. On examination, there were no subcutaneous nodules. Cardiovascular and respiratory examinations were unremarkable. There was active synovitis affecting a number of proximal interphalangeal joints and the second and third metacarpophalangeal joints bilaterally. There was synovitis of the left knee with 15° fixed flexion deformity. Blood tests showed a slightly elevated erythrocyte sedimentation rate (ESR; 21 mm/h), and she was positive for rheumatoid factor, with a titre of 1:320. She was negative for antineutrophil cytoplasmic antibodies and the angiotensin-converting enzyme level was <25 U/l (normal range 0–55 U/l). X-ray of the hands and feet showed no erosions. She responded well to intra-articular steroid injections and sulphasalazine 1 g twice daily.

Pulmonary manifestations of RA include pleural disease, pulmonary infections, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, nodules and Caplan's syndrome [3].

Pulmonary necrobiotic nodules are a rare manifestation of RA, usually associated with the presence of subcutaneous nodules. They are seen mainly in men with longstanding seropositive RA. They may vary in size. The nodules can cause haemoptysis, pneumothorax or bronchopleural fistula depending on their location. Pneumothorax in RA may be associated with eosinophilia, high ESR and other pulmonary manifestations of RA, such as pulmonary fibrosis and vasculitis [4]. Our patient also had eosinophilia at the time of presentation.

Anecdotal reports suggest that methotrexate might exacerbate subcutaneous nodulosis in RA [1]. Gotsman et al. [1] has described a case of spontaneous pneumothorax developing in an RA patient treated with methotrexate. As in other cases of pneumothorax secondary to pulmonary rheumatoid nodules, their patient was a male with longstanding RA. In view of these reports, we avoided disease-modifying treatment with methotrexate in our patient because of concern that this might aggravate pulmonary nodulosis.

To our knowledge this is the first described case of a patient with spontaneous pneumothorax due to a pulmonary rheumatoid nodule which preceded the development of RA.

The authors have declared no conflicts of interest.

References

  1. Gotsman I, Goral A, Nusair S. Secondary spontaneous pneumothorax in a patient with pulmonary rheumatoid nodules during treatment with methotrexate. Rheumatology 2001;40:350–1[Free Full Text]
  2. Crisp AJ, Armstrong RD, Grahame R, Dussek JE. Rheumatoid lung disease, pneumothorax and eosinophilia. Ann Rheum Dis 1982;41:137–40[Abstract]
  3. Adelman HM, Dupont EL, Flannery MT, Wallach PM. Recurrent pneumothorax in a patient with rheumatoid arthritis. Am J Med Sci 1994;308:171–2[ISI][Medline]
  4. Portner MM, Gracie WA Jr. Rheumatoid lung disease with cavitary nodules, pneumothorax and eosinophilia. N Engl J Med 1966;275:697–700[ISI][Medline]
Accepted 13 March 2003





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