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 0.040.4 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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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
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