ABSTRACT
Rheumatoid pleurisy is common in patients with rheumatoid arthritis, but distinguishing it from other diseases, such as heart failure and tuberculous pleurisy, is often difficult. A man in his 70s with stable rheumatoid arthritis presented with cardiac enlargement and bilateral pleural effusion on chest radiography. Pleural fluid studies showed lymphocytosis, adenosine deaminase level of 51.6 U/L and rheumatoid factor level of 2245.3 IU/mL, suggestive of rheumatoid pleurisy and tuberculous pleurisy. Thoracoscopy under local anaesthesia revealed erythema of the parietal pleura, small papillary projections and fibrin deposits. H&E-stained biopsy specimens showed inflammatory granulomas with strong lymphocytic infiltration and non-caseating granulomas. He was diagnosed with rheumatoid pleurisy. His symptoms improved with 30 mg of prednisolone. This study highlights that biopsy using thoracoscopy under local anaesthesia effectively diagnoses rheumatoid pleurisy, which may be challenging to diagnose.
Subject(s)
Anesthesia, Local , Pleurisy , Thoracoscopy , Humans , Male , Thoracoscopy/methods , Pleurisy/diagnosis , Pleurisy/pathology , Aged , Biopsy/methods , Thoracic Wall/pathology , Diagnosis, Differential , Arthritis, Rheumatoid , Prednisolone/therapeutic use , Prednisolone/administration & dosage , Pleura/pathology , Pleura/diagnostic imagingABSTRACT
Immunoglobulin G4 (IgG4)-related disease is a chronic inflammatory condition often characterized by exudative pleural effusions. However, transudative pleural effusions, like in the presented case of an 80-year-old man with multiple comorbidities, are less common but possible. Despite initial treatment with diuretics, the effusion persisted, prompting further investigation. Medical thoracoscopy revealed lymphatic follicle hyperplasia and an abundance of IgG4-positive plasmacytoid cells, confirming IgG4-related pleuritis. This case underscores the importance of considering inflammatory etiologies, such as IgG4-related disease, when faced with unresponsive transudative pleural effusions. Thoracoscopy serves as a valuable diagnostic tool in such scenarios, allowing for precise diagnosis and appropriate management.
