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LETTER TO EDITOR
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 56-58

Bilateral empyema in a patient with seropositive rheumatoid arthritis – Infective versus non-infective


Metro Centre for Respiratory Diseases, Metro Hospital, Noida, Uttar Pradesh, India

Date of Web Publication29-Dec-2016

Correspondence Address:
Dr. Arjun Khanna
Metro Centre for Respiratory Diseases, Metro Hospital, Noida, UP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.196659

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How to cite this article:
Jose A, Kuriakose M, Khanna A, Talwar D. Bilateral empyema in a patient with seropositive rheumatoid arthritis – Infective versus non-infective. J Assoc Chest Physicians 2017;5:56-8

How to cite this URL:
Jose A, Kuriakose M, Khanna A, Talwar D. Bilateral empyema in a patient with seropositive rheumatoid arthritis – Infective versus non-infective. J Assoc Chest Physicians [serial online] 2017 [cited 2021 Dec 7];5:56-8. Available from: https://www.jacpjournal.org/text.asp?2017/5/1/56/196659

Sir,

Pleuropulmonary manifestations of rheumatoid arthritis (RA) are well described. Pleural involvement in RA usually presents as exudative pleural effusion. The presence of frank empyema in RA is not common and is usually attributed to the breakdown of subpleural rheumatoid nodules with or without secondary infection.[1] It is important to find out if empyema in a patient with RA is due to pleural space infection or inflammatory rheumatoid flare, as the treatment of the two conditions is diametrically opposite.

A 56-year-old female with polyarticular RA, on irregular treatment for the past 20 years, presented with fever and shortness of breath over the past 7 days. History revealed that she was on irregular therapy with oral prednisolone, methotrexate, and leflunomide. For the past 6 months, she had left all treatment and was on some indigenous treatment for the RA, which she claimed worked better for the joint pains than any of the other medications she had tried in the past. On evaluation, she was febrile (101F), had a respiratory rate of 33/min, blood pressure was 120/80 mmHg. Room air saturation was maintained at 98%, which did not dip significantly on doing any activity. Joint deformities classical of RA were noticed in multiple joints of the appendicular skeleton. Bony deformity of the left forearm was noted, which occurred subsequent to spontaneous osteomyelitis, for which she had undergone multiple surgeries 3 years ago.

Clinical examination was suggestive of left-sided pleural effusion, which was corroborated with a blunt, left-sided cardiophrenic angle on the chest X-ray. Routine blood investigations revealed that hemoglobin level of 9.8 g/dL, total leukocyte count was 12,800/cumm with 90% neutrophils. Liver and renal function tests were within the normal range. Serum procalcitonin level was not raised and was 0.03 ng/mL. Serum rheumatoid factor (RF) was 455 units/L. Serum cyclic citrulinated peptide (CCP) antibody was highly elevated and was 298 units. High-resolution CT scan of the thorax was suggestive of left-sided pleural effusion, with associated lobar consolidation in the left lower lobe and right middle lobe [Figure 1].
Figure 1: CT chest showing left-sided pleural effusion with left lower lobe pneumonia

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Diagnostic thoracocentesis from the left side revealed grossly turbid fluid. Pleural fluid analysis revealed that pH was 7.15, glucose 10 mg/dL (plasma glucose at the time was 88 mg/dL), pleural protein 5.1 g/dL (serum protein 6.9 g/dL), and pleural lactate dehydrogenase (LDH) 10,655 units/L (serum LDH 243 units/L). Gram staining and culture studies were negative for organisms, and cytology revealed acute inflammatory cells and no malignant cells. These findings were consistent with those of empyema, and the empyema was drained with intercostal tube drainage (ICD). In view of the underlying consolidation, the process was thought to be infective, and the patient was started on intravenous ceftriaxone and vancomycin. The procalcitonin levels that were negative, however, did not support the theory of infective empyema. The low sugar in the pleural fluid and the very high LDH levels were suggestive of empyema, but similar findings have also been reported in RA-associated pleural effusion.[1],[2] As a result of this diagnostic dilemma, it was decided to do a thoracoscopic pleural biopsy and obtain samples for further evaluation. Medical thoracoscopy revealed grossly thickened parietal pleura with multiple adhesions. Multiple pleural biopsies were taken from the parietal pleura. Post-procedure, in view of the multiple adhesions, the pleural space was instilled with five sittings of urokinase. Over the next 5 days, the patient showed clinical and radiological improvement.

The pleural biopsy was suggestive of extensive fibrinoid necrosis with polymorphonuclear infiltration [Figure 2]. No granulomas, malignant cells, acid-fast, or other bacteria were observed. These findings could be seen in both RA or an infective process.[2]
Figure 2: The pleural biopsy demonstrating extensive fibrinoid necrosis with polymorphonuclear infiltration

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After 5 days of intrapleural urokinase therapy, the ICD output was less than 50 mL/day, and it was decided to remove the tube. The patient developed second episode of high-grade fever with chills. Chest X-ray performed at this point, revealed blunting of the right-sided cardiophrenic angle. An ultrasound-guided transversus abdominis plane (TAP) of the right pleural effusion revealed grossly turbid fluid. Analysis of the pleural fluid showed similar results as that of the left-sided pleural effusion, with very high LDH levels and low glucose, which were suggestive of empyema. The right-sided empyema was also drained with ICD tube. A repeat CT scan revealed right-sided pleural space infection, which was consistent with empyema with minimal pleural fluid on the left side [Figure 3]. The consolidation on the left side and the few alveolar infiltrates of the right middle lobe had disappeared. There were no rheumatoid nodules, which could have cavitated and then led to empyema.
Figure 3: Repeat CT scan revealed right-sided pleural space infection, consistent with empyema with minimal pleural fluid on the left side

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Repeat blood tests did not reveal any evidence of infection, and repeat procalcitonin levels were again negative (0.02 ng/mL). The intravenous antibiotics were continued, but the fever spikes also continued. Blood cultures were negative; urine routine examination and microscopic examination did not reveal any infection. The malarial parasite was not detected in the peripheral smear, and the malarial antigen test was negative. Ultrasound abdomen, and 2D Echo were also normal. The patient had a rheumatology consultation, and in view of the absence of any discernable infection and high titers of RA factor and CCP, she was started on 40 mg/day of oral prednisolone. Over the next 2 days, the fever spikes decreased, and the patient became comfortable.

Our patient had come with a left-sided empyema that was secondary to the underlying pneumonia, but her hospital stay was complicated by the right-sided empyema, which was probably as a result of the flare of the rheumatoid inflammation. We could not measure pleural fluid RA factor or CCP antibody levels, which would have further strengthened our diagnosis. The patient was given 14 days of intravenous antibiotics and was discharged on oral prednisolone and hydroxychloroquine sulphate with advice to follow-up closely. One month after discharge, the patient was comfortable, and repeat chest X-ray revealed clearing of the bilateral effusions.

Although considerable literature exists on rheumatoid pleural effusion,[3] the term "Rheumatoid empyema" is sparingly discussed. Multiple etiologies have been attributed to the development of empyema in a patient with RA.[4] These include steroid therapy, decreased resistance to infection, and chronic bronchopulmonary infections in patients on immunosuppressant therapy for RA. The preexistence of rheumatoid pleural effusion in a patient with RA also predisposes to the development of empyema. The formation of bronchopleural fistulas through necrotic subpleural rheumatoid nodules has also been linked to chronic pleural space infections in these patients.

The exact management of these empyemas is unclear. Most physicians would start these patients on antibiotics and drain the pleural fluid, as it is very difficult to distinguish this form of empyema from infective empyema. Absence of bacteria on Gram staining of the pleural fluid and negative bacterial cultures with negative procalcitonin levels may hint toward a non-infective etiology of this empyema. In our patient the first empyema was Gram-stain and culture negative, with low serum procalcitonin levels; we attributed it to the underlying left lower lobe consolidation. High levels of RA factor and anti-CCP levels indicated ongoing rheumatoid inflammation in our patient, and the same has been linked with extra-articular manifestations of RA.[5]In the case of more complicated, infected, and loculated rheumatoid effusions, surgery with decortications had been tried.[6] Good control of the underlying rheumatoid inflammation is essential in controlling rheumatoid effusions and may be done with steroids, non-steroidal anti-inflammatory drugs and disease-modifying drugs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Stout J, Hayes D, Rojas-Moreno C, Clary K, See WM. Rheumatoid pleural effusions and trapped lung: An uncommon complication of rheumatoid arthritis. J Acad Hosp Med 2015;7.  Back to cited text no. 1
    
2.
Scott DL, Wolfe F, Huizinga TW. Rheumatoid arthritis. Lancet 2010;376:1094-108.  Back to cited text no. 2
    
3.
Balbir-Gurman A, Yigla M, Nahir AM, Braun-Moscovici Y. Rheumatoid pleural effusion. Semin Arthritis Rheum 2006;35:368-78.  Back to cited text no. 3
    
4.
Yigla M, Simsolo C, Goralnik L, Balabir-German A, Nahir AM. The problem of empyematous pleural effusion in rheumatoid arthritis: Report of two cases and review of the literature. Clin Rheumatol 2002;21:180-3.  Back to cited text no. 4
    
5.
Bouros D, Pneumatikos I, Tzouvelekis A. Pleural involvement in systemic autoimmune disorders. Respiration 2008;75:361-71.  Back to cited text no. 5
    
6.
Rueth N, Andrade R, Groth S, D’Cunha J, Maddaus M. Pleuropulmonary complications of rheumatoid arthritis: A thoracic surgeon’s challenge. Ann Thorac Surg 2009;88:e20-1.  Back to cited text no. 6
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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