Rheumatology International

, Volume 27, Issue 10, pp 919–925

Pleural effusion associated with rheumatoid arthritis: what cell predominance to anticipate?

  • L. Sølling Avnon
  • M. Abu-Shakra
  • D. Flusser
  • D. Heimer
  • N. Sion-Vardy
Case Report

DOI: 10.1007/s00296-007-0322-9

Cite this article as:
Avnon, L.S., Abu-Shakra, M., Flusser, D. et al. Rheumatol Int (2007) 27: 919. doi:10.1007/s00296-007-0322-9

Abstract

Pleural involvement is the most frequent manifestation of rheumatoid arthritis (RA) in the chest. We report here two patients who presented with large exudative pleural effusions and subsequently developed sero-positive RA. In both cases, the differential cell count of the pleural effusion suggested empyema. A literature review identified that RA-associated pleural effusion afflicts more men than women and 95% of the patients have high titers of rheumatoid factor (RF). In 46% of cases, RA-associated pleural effusion is diagnosed in close temporal relationship with the diagnosis of RA. The effusion is an exudate and is characterized by low pH and glucose level, and high lactic dehydrogenase (LDH) and cell count. At diagnosis there is a tendency for predominant neutrophils to occur consistent with an empyema and 7–11 days later, the cells in the pleural effusion are replaced by lymphocytes. Pleural effusion with predominant eosinophilia is rare. RA patients with acidic effusion and low glucose content with neutrophils predominance should be treated with thoracic drainage and antibiotics until an infection is ruled out. The histo-pathologic findings in pleural fluid of tadpole cells and multinucleated giant cells and the replacement of the mesothelial cells on the parietal pleural surface with a palisade of macrophage derived cells are described as pathogonomic for RA. Treatment with systemic steroids and intra-pleural steroids are effective in most cases.

Keywords

Pleural effusion Rheumatoid arthritis Aseptic empyema Eosinophilia Tadpole cells 

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • L. Sølling Avnon
    • 1
  • M. Abu-Shakra
    • 2
    • 4
  • D. Flusser
    • 2
  • D. Heimer
    • 1
  • N. Sion-Vardy
    • 3
  1. 1.Pulmonary ClinicSoroka University Medical Center, and Faculty of Health Sciences at Ben Gurion University of the NegevBeer ShevaIsrael
  2. 2.Rheumatic Diseases UnitSoroka University Medical Center, and Faculty of Health Sciences at Ben Gurion University of the NegevBeer ShevaIsrael
  3. 3.Pathological InstituteSoroka University Medical Center, and Faculty of Health Sciences at Ben Gurion University of the NegevBeer ShevaIsrael
  4. 4.Department of Medicine DSoroka Medical CenterBeer ShevaIsrael