Rheumatoid pleuritis

Pleural Diseases in Connective Tissue Diseases

Connective tissue diseases (CTD) are heterogeneous, immune-mediated inflammatory disorders often presenting with multiorgan involvement. With the advent of high-resolution computed tomography, CTD-related pleuritis-pleural thickening and effusion-is now increasingly recognized early in the disease trajectory. The natural history of CTD-related pleural effusions varies from spontaneous resolution to progressive fibrothorax with ventilatory impairment. Treatment of the underlying CTD is necessary to manage the pleural disease. Depending on the degree of symptom burden and physiological insult, specific treatment of pleural disease can include monitoring, repeated aspirations, systemic anti-inflammatory medication, and surgical decortication.

Concomitant Large Loculated Pleural and Pericardial Effusions in a Patient with Rheumatoid Arthritis on Methotrexate

Rheumatoid arthritis (RA) is the most common multisystemic autoimmune inflammatory joint disorder, affecting nearly 1.3 million adults in the US. RA has high economic and social burdens. Functional disability may arise in RA from the characteristic chronic progressive inflammation and the erosion of multiple joints and cartilage damage. Systemic manifestations of RA include rheumatoid nodules, pleuropulmonary complications, pericarditis, rheumatoid vasculitis, Felty's syndrome (the rare triad of rheumatoid arthritis, splenomegaly, and neutropenia), amyloidosis, and neurological complications. We present the diagnostic challenges of differentiating pleuropulmonary and pericardial complications of rheumatoid arthritis from side effects of therapy (rheumatoid pleural and pericardial effusions vs immune suppression associated side effects and infections). We use the Naranjo score to facilitate this decision-making process. A 52-year-old man with a history of RA, chronic small right pleural effusion, and hypertension on long-term oral methotrexate and corticosteroid therapy presented to the emergency room after 1 week of worsening respiratory symptoms. A chest radiograph demonstrated a large pleural effusion and pneumonia. Intravenous methylprednisolone and antibiotics were administered. A video-assisted thoracoscopic procedure was performed, chest tubes were inserted, and abatacept was eventually initiated as adjunctive therapy to methotrexate and corticosteroid therapy for the rheumatoid arthritis and lung condition. Abatacept is an immunosuppressive fusion protein composed of the Fc region of immunoglobulin G1 fused to the extracellular domain of cytotoxic T-lymphocyte-associated protein 4, which interferes with the immune activity of T cells.

Rheumatoid arthritis increases the risk of pleural empyema

Background

Rheumatoid arthritis (RA) can lead to various pulmonary manifestations. Evidence shows the possible association between RA and pleural empyema.

Methods

We conducted a retrospective cohort study to investigate the risk of pleural empyema in patients with RA. The RA group (n = 29,061) included newly diagnosed adult patients between 2000 and 2012. The comparison group (n = 1,16,244) included individuals without RA at a 1:4 ratio of frequency matched by age, gender, and diagnosis year. The occurrence of pleural empyema was monitored until the end of 2013.

Results

Patients with RA had a higher risk of developing pleural empyema than those without RA (23.6 vs 1.82 per 10,000 person-years, adjusted hazard ratio = 11.0, 95% confidence interval [CI] = 8.90–13.5). Furthermore, intensive care unit admission rates of pleural empyema were 37.7% in the RA group and 37.2% in the comparison group (adjusted odds ratio [OR] = 1.02, 95% CI = 0.66−1.57). The 30-day mortality rates of pleural empyema were 11.2% in the RA group and 10.9% in the comparison group (adjusted OR = 1.01, 95% CI = 0.51−1.88).

Conclusion

Patients with RA are at a greater risk of developing pleural empyema than those without RA.

Retrospective investigation on diagnostic process for benign asbestos pleural effusion (BAPE) using checklist

OBJECTIVES

In Japan, benign asbestos pleural effusion (BAPE) has been eligible for industrial accident compensation since 2003 as an asbestos-related disease despite the lack of good criteria. We compiled a criteria into a checklist of essential items and for excluding other diseases inducing pleural effusion as a diagnosis process.

METHOD

Thoracentesis was performed in order to confirm the presence of pleural effusion at the initial diagnosis, and 105 suspected BAPE patients were retrospectively examined. We complied a checklist comprising the following diagnostic items: (a) occupational asbestos exposure; (b) confirmation of exudate of pleural effusion; (c) exclusion of pleural effusion with malignant tumors based on negative results of CEA and hyaluronic acid, and cytology of pleural effusion; (d) exclusion of rheumatic, bacterial, and tuberculous pleuritis; (d) radiological findings for exclusion of malignancies; and (e) histopathological findings based on thoracoscopy that exclude malignancies (when thoracoscopy was not performed, there was confirmation that no malignancies were present during 3-month follow-up observation). Cases that satisfied all items were defined as BAPE.

RESULTS

Among the 105 suspected cases, there were five cases that had no occupational asbestos exposure; six cases in which transudate of on pleural effusion; one case each of rheumatoid pleuritis and tuberculous pleuritis; and five cases of pleural mesothelioma based on chest radiography and histopathological findings within 3 months after initial diagnosis. Therefore, we excluded 18 cases from the 105 candidates and determined 87 cases of BAPE.

CONCLUSION

We consider that six items described above are suitable for diagnosing BAPE.

Mechanisms of lung disease development in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes joint inflammation and damage. Extra-articular manifestations occur in many patients and can include lung involvement in the form of airway or parenchymal inflammation and fibrosis. Although the pathophysiology of articular RA has been extensively investigated, the mechanisms causing airway and parenchymal lung disease are not well defined. Infections, cigarette-smoking, mucosal dysbiosis, host genetics and premature senescence are all potentially important contributors to the development of lung disease in patients with RA. RA-associated lung disease (which can predate the onset of articular disease by many years) probably originates from chronic airway and alveolar epithelial injury that occurs in an individual with a genetic background that permits the development of autoimmunity, leading to chronic inflammation and subsequent airway and lung parenchymal remodelling and fibrosis. Further investigations into the specific mechanisms by which lung disease develops in RA will be crucial for the development of effective therapies. Identifying mechanisms by which environmental and host factors cooperate in the induction of autoimmunity in the lung might also help to establish the order of early events in RA.

Thoracic Manifestations of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is commonly associated with pulmonary disease that can affect any anatomic compartment of the thorax. The most common intrathoracic manifestations of RA include interstitial lung disease, airway disease, pleural disease, rheumatoid nodules, and drug-induced toxicity. Patients with RA with thoracic involvement often present with nonspecific respiratory symptoms, although many are asymptomatic. Therefore, clinicians should routinely consider pulmonary disease when evaluating any patient with RA, particularly one with known risk factors. The optimal screening, diagnostic, and treatment strategies for RA-associated pulmonary disease remain uncertain and are the focus of ongoing investigation.

Updates in Effusion Cytology

Effusion cytology plays multiple roles in the management of benign and malignant disease, from primary diagnosis to tissue allocation for ancillary diagnostic studies and biomarker testing of therapeutic targets. This article summarizes recent advances in pleural effusion cytology, with a focus on the practical application of immunohistochemical markers, cytogenetic techniques, flow cytometry, and molecular techniques for the diagnosis and management of primary and secondary neoplasms of the pleura.

Lung involvement in inflammatory rheumatic diseases

This chapter describes the involvement of the lung in systemic inflammatory joint disease (IJD) with a particular focus on rheumatoid arthritis, although the topics of pulmonary involvement in ankylosing spondylitis and psoriatic arthritis are also addressed. Interstitial lung disease is the most lethal pulmonary complication of IJD and the chapter describes recent advances in both our understanding of this complication and the therapeutic options that offer real hope for improved outcomes. Although less well recognised, airways disease is just as common and its association with IJD is described in some detail, with a section devoted to the recent surge in interest in bronchiectasis. Acute pulmonary infection is common in IJD and its management is reviewed in some detail. Although pleural disease is less common than it once was, its treatment is explored. We conclude by reviewing the relationship between the drug therapies employed in IJD and their effects on the lung.

Rheumatoid arthritis-associated lung disease

Comprehensive, up-to-date review of RA-associated lung diseases including pathogenesis and managementhttp://ow.ly/FBaNZ

Intra-thoracic rheumatoid arthritis: Imaging spectrum of typical findings and treatment related complications

Non-cardiac thoracic manifestations of rheumatoid arthritis (RA) cause significant morbidity and mortality among RA patients. Essentially all anatomic compartments in the chest can be affected including the pleura, pulmonary parenchyma, airway, and vasculature. In addition, treatment-related complications and opportunistic infections are not uncommon. Accurate diagnosis of intra-thoracic disease in an RA patient can be difficult as the radiologic findings may be nonspecific and many of these conditions may coexist. This review article serves to highlight the multitude of RA-related intra-thoracic pathological processes, emphasize differential diagnosis, diagnostic conundrums and discuss how tailoring of CT imaging and image-guided biopsy plays a key role in the management of RA-related pulmonary disease.

Rheumatoid pleural effusion with nodular pleuritis. A rare presentation of rheumatoid arthritis

Rheumatoid pleural effusion and lung nodules are unusual complications of rheumatoid disease that typically present subsequently to other more common manifestations of rheumatoid illness. However, these complications may occasionally occur before or concurrently with the development of joint manifestations of disease. We report the case of a 41-year-old female patient with rheumatoid pleural effusion and lung nodule arising simultaneously with the onset of joint symptoms. The patient underwent thoracentesis followed by video-assisted thoracoscopic biopsy to result in a diagnosis of rheumatoid pleuritis and nodular disease. A high index of suspicion and coexistence of the cytologic and histopathologic effusion picture characteristic of rheumatoid pleuritis are of clinical importance in making a diagnosis.

Getting the most from pleural fluid analysis

Virtually, every pulmonary disease and most non-pulmonary diseases may be associated with a pleural effusion. The presence of a pleural effusion allows the clinician to 'diagnose' or narrow the differential diagnosis and aetiology of the fluid collection. However, pleural fluid analysis (PFA) in isolation rarely provides a definitive diagnosis. This review discusses the rationale for evaluating patients with a pleural effusion. If the clinician obtains a detailed history, performs a comprehensive physical examination, reviews pertinent blood tests, and evaluates the chest imaging findings prior to thoracentesis, there should be a high likelihood of establishing a firm clinical diagnosis based on the appropriate PFA. This manuscript reviews the clinical presentation, chest imaging findings, duration and natural course of specific pleural effusions to help narrow the range of pre-thoracentesis diagnoses. A diagnosis of transudative effusion confirms an imbalance in hydrostatic and oncotic pressures, normal pleura and a limited differential diagnosis, which is typically apparent from the clinical presentation. Exudates are the result of infections, malignancies, inflammation, impaired lymphatic drainage or the effects of drugs, and pose a greater diagnostic challenge. The differential diagnosis for a pleural exudate can be narrowed if LDH levels exceed 1000 IU/L, the proportion of lymphocytes is ≥80%, pleural fluid pH is <7.30 or there is pleural eosinophilia of >10%.

Adenosine deaminase in the diagnosis of pleural effusions

The activity of adenosine deaminase (ADA) was determined in serum and pleural fluid of 90 patients with pleural effusions of various aetiology. Tuberculous pleural effusions, empyemas and rheumatoid pleural effusions demonstrated significantly higher activities of ADA than parapneumonic , nonspecific and malignant pleural effusions and effusions in systemic lupus erythematosus and congestive heart failure. In tuberculosis, empyema and rheumatoid arthritis ADA activity was significantly higher in pleural fluid than in serum, indicating a local synthesis of ADA by cells within the pleural cavity in these diseases.

Collagen Vascular Diseases and Disorders of Connective Tissue

The collagen vascular diseases, also referred to as connective tissue diseases, are a diverse group of systemic inflammatory disorders thought to be immunologically mediated. The concept of collagen vascular disease began to take shape in the 1930s, when it was recognized that rheumatic fever and rheumatoid arthritis can affect connective tissues throughout the body.1,2 During the following decade, as conditions such as systemic lupus erythematosus (SLE) and scleroderma came to be viewed as systemic diseases of connective tissue, the terms diffuse connective disease and diffuse collagen disease were proposed.3,4 During the same period, the designation of diffuse vascular disease was proposed for diseases such as scleroderma, polymyositis, SLE, and polyarteritis nodosa, which featured widespread vascular involvement.5 With the realization that many of these entities can exhibit both systemic connective tissue manifestations and vascular abnormalities, the unifying designation of collagen vascular disease was introduced.6

Rheumatoid Pleural Effusion

OBJECTIVES

To describe the clinical and laboratory features of rheumatoid pleural effusion (RPE) and the diagnostic and therapeutic approaches to this condition.

METHODS

The review is based on a MEDLINE (PubMed) search of the English literature from 1964 to 2005, using the keywords "rheumatoid arthritis" (RA), "pulmonary complication", "pleural effusion", and "empyema".

RESULTS

Pleural effusion is common in middle-aged men with RA and positive rheumatoid factor (RF). It has features of an exudate and a high RF titer. Underlying lung pathology is common. Generally RPE is small and resolves spontaneously but symptomatic RPE may require thoracocentesis. Rarely, RPE has features of a sterile empyematous exudate with high lipids and lactate dehydrogenase, and very low glucose and pH levels. This type of effusion eventually leads to fibrothorax and lung restriction. Superimposed infective empyema often complicates RPE. Oral, parenteral, and intrapleural corticosteroids, pleurodesis and decortication, have been used for the treatment of sterile RPE. Infected empyema is treated with drainage and antibiotics.

CONCLUSIONS

RPE may evolve into a sterile empyematous exudate with the development of fibrothorax. Symptomatic effusions or suspicion of other causes of exudate (infection, malignancy) require thoracocentesis. The "rheumatoid" nature of the pleural exudate in patients without arthritis mandates a pleural biopsy to exclude tuberculosis or malignancy. The optimal therapy of RPE has yet to be established. The role of cytokines in the course of RPE and the possible usefulness of cytokine blockade in the treatment of this RA complication require further evaluation.

Systemische Manifestationen der rheumatoiden Arthritis

Extra-articular manifestations of rheumatoid arthritis are gaining in importance both in rheumatology and other specialities. This report provides information on various organ manifestations and interactions between mere disease-related symptoms and therapeutic effects. Diagnostic radiology plays a crucial role in finding the diagnosis, planning and monitoring of treatment, early detection of complications and drug-related adverse events.

Rheumatoid Pleural Effusion in the Absence of Arthritic Disease

Rheumatoid pleural effusion is an unusual complication of rheumatoid disease that typically presents subsequent to other more common manifestations of rheumatoid illness. The case of a 72-year-old woman with a rheumatoid pleural effusion is discussed. The patient presented with dyspnea, but without any history of rheumatoid arthritis. The patient was treated by thoracentesis, followed by video-thoracoscopy and pulmonary decortication. Postoperatively, the patient's effusion partially reaccumulated. Steroid therapy resulted in prompt and permanent resolution of the effusion. The patient remains asymptomatic 1 year after her presentation. The biochemical, serologic, and cytologic characteristics of rheumatoid effusions are reviewed.

Pathology of interstitial lung disease

A large and diverse group of pathologic conditions manifests clinically and radiologically as diffuse parenchymal lung disease. Diffuse interstitial lung diseases (ILDs) encompass mainly inflammatory processes that involve the structural elements of this organ. Some ILDs are caused by infections, but most are the result of immunologic, environmental, or toxic mechanisms. Currently, less morbid sampling techniques have increased dramatically the probability that pulmonologists will be faced with establishing a specific and clinically relevant diagnosis using surgical lung biopsy material. Most of the concepts presented in this article have been established using this type of specimen. In the early years of surgical lung biopsy, a small number of diffuse inflammatory conditions came to light that exclusively involved the lungs and did not seem to be caused by infection, toxin, sarcoidosis, pneumoconiosis, or neoplasm. In this article, these idiopathic disorders are discussed in the context of their dominant pathologic findings rather than presented as a separate group of entities.

Patient with bilateral pleural effusion: are the findings the same in each fluid?

STUDY OBJECTIVES

To determine whether, in patients with bilateral pleural effusions, the main cellular and biochemical features of the pleural fluid on the right side differ from or correlate with those on the left side. We examined lactate dehydrogenase (LDH), glucose, and total protein (TP) levels, RBC count, nucleated cell count (NCC), and differential cell count.

PATIENTS AND METHODS

Twenty-seven patients with bilateral pleural effusions, including 13 patients with effusions after coronary artery bypass graft surgery, 12 patients with congestive heart failure, 1 patient with malignant pericarditis, and 1 patient with renal failure, were studied retrospectively.

RESULTS

The right-sided and the left-sided pleural effusions did not differ in the mean TP (p = 0.38), glucose (p = 0.31), and LDH (p = 0.39) levels, RBC count (p = 0.31), NCC (p = 0.96), and the percentage of neutrophils (p = 0.22), lymphocytes (p = 0.73), mononuclear cells (MNCs) [p = 0.49], and eosinophils (p = 0.65). The bias +/- precision was 0.1 +/- 0.64 g/dL for TP, - 2.7 +/- 23 mg/dL for glucose, 41 +/- 362 IU/L for LDH, 6,100 +/- 62,900 cells/ micro L for RBC count, - 36 +/- 1,043 cells/ micro L for NCC, - 2.9 +/- 11.6% for the percentage of neutrophils, 1.15 +/- 17% for the percentage of lymphocytes, 2.3 +/- 17% for the percentage of the MNCs, and - 0.15 +/- 5.4% for the percentage of eosinophils. Moreover, there was a close correlation between the right-sided and the left-sided pleural effusions concerning TP level (r = 0.85, p < 0.001), glucose level (r = 0.78, p < 0.001), LDH level (r = 0.71, p < 0.001), RBC count (r = 0.66, p < 0.001), NCC (r = 0.60, p = 0.001), and the percentage of neutrophils (r = 0.77, p < 0.001), lymphocytes (r = 0.77, p < 0.001), MNCs (r = 0.74, p < 0.001), and eosinophils (r = 0.84, p < 0.001).

CONCLUSION

Since the pleural fluid findings tend to be similar in both sides of patients with bilateral pleural effusion, we suggest that diagnostic thoracentesis may not need to be performed on both sides, unless there is a specific clinical indication.

Pleuritis as a presenting manifestation of rheumatoid arthritis: diagnostic clues in pleural fluid cytology

Pleural effusion is a recognized but relatively uncommon complication of rheumatoid arthritis and has distinctive cytopathologic features. It may occur before, concurrently with, or after the development of joint manifestations of the disease. Clinical diagnosis of rheumatoid pleuritis may be delayed or overlooked in a patient without obvious evidence of arthritis. Failure to recognize the unique cytologic picture of rheumatoid pleuritis caused a 5-month delay in diagnosis of a rheumatoid pleural effusion in an elderly man whose concurrent arthritic symptoms were not given adequate clinical recognition.

Clinical management of the patient with pleural effusion

Pleural effusion is a frequent medical problem with a wide span of different causes. We wish to highlight the clinical management of the patient with pleural effusions but anatomic, physiologic and diagnostic management of the main pleural diseases will also be considered.

Pulmonary manifestations of rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common of the classic connective tissue diseases. Its manifestations in the chest are varied as the pleura, lung parenchyma, airways, and pulmonary vasculature can all be involved. The approach to a patient with RA and respiratory complaints, radiographic findings, or physiologic abnormalities requires a broad understanding of these manifestations. Moreover, the potential for therapy-related toxicity adds further complexity to the pulmonary evaluation of these patients.

Radiologic manifestations of the systemic autoimmune diseases

Advances in thoracic imaging during the past two decades, such as CT scans and MR imaging, have enhanced our understanding of the pleuropulmonary abnormalities that develop in the systemic autoimmune diseases. In this article, the thoracic radiologic manifestations of several connective tissue diseases (systemic lupus erythematosus, rheumatoid arthritis, Sjögren's syndrome, polymyositis/dermatomyositis, progressive systemic sclerosis, and anklyosing spondylitis), two granulomatous vasculitides, (Wegener's Granulomatosis and Churg-Strauss syndrome), and antiglomerular basement membrane disease are reviewed.

[Pleural effusion as initial presentation of rheumatoid arthritis. Cytological diagnosis]

A 24-year-old woman with an unremarkable history presented with a large right-sided pleural effusion. Analysis of the pleural fluid showed a sterile exudate with a low sugar level. Complementary analyses were unable to pinpoint the etiology. The effusion was drained and the patient was released with no specific diagnosis. Nine months later the effusion recurred and the initial laboratory analyses were the same. Pleural fluid cytology revealed the presence of an amorphous necrotic background and non-small cells with multiple nuclei, two signs that constitute part of the pathognomonic triad of rheumatoid pleural effusions, the third characteristic benign fusiform histocytes. The biochemical characteristics of the pleural fluid thus suggested rheumatoid pleural effusion, and cytology confirmed the diagnosis. Corticoid therapy effected spectacular recovery, but when the dose was reduced, rheumatoid symptoms presented in the joints. Rheumatoid arthritis should be considered as a possible explanation for unexplained pleural effusion. Cytology must be used for diagnosis.

Evolution of idiopathic pleural effusion: a prospective, long-term follow-up study

The management of idiopathic pleural effusion remains controversial. Because the long-term evolution of this entity is not well known, two different approaches, aggressive and conservative, have been proposed. We conducted a 10-year study of the evolution of idiopathic pleural effusion.

METHODS

Between 1984 and 1994, we prospectively studied 40 consecutive patients (30 men and 10 women; mean [+/- SD] age, 53.8 +/- 19.4 years) with exudative pleural effusion undiagnosed after exhaustive evaluation. The pleural fluid adenosine deaminase level was below 43 IU/L in all; periodic chest radiographs and clinical evaluation were carried out in all patients for a mean of 62 months (range, 36 to 108 months). Further diagnostic procedures were performed whenever the effusion recurred or when indicated by the clinical picture.

RESULTS

Effusions resolved in a mean time of 5.6 months (range, 7 days to 48 months). Five patients (12.5%) had one or more relapses of their pleural effusion, and in a further 5 (12.5%), the effusion persisted unchanged for more than 1 month. In 32 cases (80%), no potential cause of the effusion was detected. The diagnoses in the remaining eight cases were asbestos pleural effusion in three, pulmonary adenocarcinoma in one, mesothelioma in one, congestive heart failure in one, liver cirrhosis in one, and rheumatoid arthritis in one. Tuberculosis was not detected in any of the cases, although 19 patients initially had positive tuberculin tests.

CONCLUSIONS

Most idiopathic pleural effusions follow a benign course. Our results support conservative treatment of patients with idiopathic pleural effusion. Antituberculous treatment does not appear to he warranted, regardless of tuberculin test results, if the pleural fluid adenosine deaminase level is not elevated.

Pulmonary involvement in rheumatoid arthritis

Pulmonary involvement is one of the extra-articular manifestations of rheumatoid arthritis (RA) and includes pleurisy, parenchymal nodules, interstitial involvement, and airway disease. Rheumatoid pulmonary vasculitis is rare. Pulmonary disease also may be observed as a toxic event consequent to treatment for RA. Although RA is more common in women, rheumatoid lung disease occurs more frequently in men who have long-standing rheumatoid disease, positive rheumatoid factor and subcutaneous nodules. Pleural involvement, usually asymptomatic, is the most common manifestation of lung disease in RA and may occur concurrently with pulmonary nodulosis or interstitial disease. The clinical features and course of pulmonary fibrosis in RA are similar to those of idiopathic pulmonary fibrosis. Bronchiolitis obliterans organizing pneumonia (BOOP), which has been recently described in RA patients, has nonspecific clinical features. The histological patterns correspond to proliferative bronchiolitis in the airway and organizing pneumonia in the alveoli. Obstructive lung disease in RA includes obliterative bronchiolitis (OB) and bronchiectasis. OB is an acute illness characterized histologically by a constrictive bronchiolitis. It may be idiopathic or induced by D-penicillamine or intramuscular gold compounds. Methotrexate (MTX)-pneumonitis is an uncommon complication of MTX treatment. Its clinical presentation is not specific, and diagnosis must be made after exclusion of other causes of pulmonary diseases. It is uncertain if preexisting lung disease predisposes RA patients to MTX-pneumonitis. Treatment of lung disease in RA is empirical. Corticosteroids are usually administered and immunosuppressive drugs are often added when pulmonary disease progresses and/or steroid side-effects appear.

Pericardial and pulmonary involvement in rheumatoid arthritis in Turkey

Pericardial and lung involvement in rheumatoid arthritis (RA), suspected to be less severe in a developing nation (Turkey), have been evaluated. We have studied clinical, echocardiographic and pulmonary findings (radiological and functional) in 93 consecutive Turkish patients with definite/classical RA. Findings were compared with those of a group of patients with osteoarthritis or local rheumatological conditions (n = 60) in a blind protocol. Fifty patients with systemic lupus (SLE) were studied as a high risk control group for pericardial involvement. While pericardial disease was detected in 5.5% (5/90) of RA patients, it was detected in 6.6% (4/60) of the control patients. SLE patients had a 26% (13/50) prevalence. Interstitial lung disease was found in 27.7% of RA patients but it was present in 6.6% (4/60) of the control patients. We observed that a group of patients with RA in Turkey had a low prevalence of pericardial disease. This is further evidence that RA has a mild course in developing countries.

Small airway disease in rheumatoid arthritis

Variety of pulmonary lesions are thought to be associated with rheumatoid arthritis (RA). These lesions traditionally have included pleurisy with or without effusion, Caplan's syndrome, pulmonary rheumatoid nodules, diffuse interstitial fibrosis, and pulmonary arteritis and hypertension. But little attention has been paid to the airways in RA. Recently, several reports have suggested an association between airflow limitation and RA, but its incidence is not known. Also whether there exists a parameter of disease activity of RA, suggesting the presence of small airway disease (SAD) is not clear. To answer these questions, the serologic parameters which reflect the disease activity of RA and pulmonary function tests which reflect small airway dysfunction were performed on 36 lifetime nonsmokers with RA who had normal chest x-ray findings. The prevalence of SAD and the relationships between the disease activity parameters of RA and pulmonary function were observed. The results were as follows. The percentages of patients with abnormal values for diffusing capacity, frequency dependence of compliance (C1.0/C0.0), forced expiratory flow 25-75%, Vmax50% and Vmax 75% were 45.5%, 62.5%, 40%, 22.8% and 11.4%, respectively. There was statistically significant negative correlation between C1.0/C0.0 and ESR. But consistent correlation between other pulmonary function tests and clinical and serologic parameters of RA, and differences in pulmonary function between patients who were serologically positive and negative for CRP and FANA, were not found. In conclusion, SAD, without the influence of smoking, is frequently associated with RA, but the presence of SAD cannot be predicted from any clinical and serologic parameters of RA currently in use.

HLA-DQw alloantigens and pulmonary dysfunction in rheumatoid arthritis

HLA-DR4 and keratoconjunctivitis sicca (secondary Sjögren's syndrome) are associated with abnormal pulmonary function in patients with rheumatoid arthritis. Since recent investigations have found that much of the genomic polymorphism of the HLA-DR4 haplotype comes from the closely linked DQw allele, we reanalyzed this set of data to evaluate the relationship between the DQw allotypes and pulmonary function in rheumatoid arthritis. Using a step-wise regression analysis, we found that the presence of DQw1 was a stronger predictor of an abnormal forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and carbon monoxide diffusing capacity (D) than the presence of DR4, keratoconjunctivitis sicca, smoking status, or any other clinical parameter. DQw1-positive patients had a mean (+/- SD) percent of predicted FEV1, FVC, and D of 84.2 (+/- 19.8), 88.0 (+/- 17.9) and 85.6 (+/- 20.9) percent, respectively, all significantly lower than DQw-1 negative patients (p = 0.02, 0.02, and 0.03). Smokers with the heterozygous phenotype, DQw1/DQw3, tended to have obstructive disease of the airways, with a mean (+/- SD) FEV1 of 80.1 +/- 24.4 percent of predicted, compared to 95.7 +/- 12.1 percent of predicted in DQw1/DQw3-negative individuals (p = 0.03). Patients who had a DQw2 allele were more likely to have normal pulmonary function. We conclude that the HLA-DQw1 allotype is a strong predictor of abnormal pulmonary function and that it may identify smoking subjects with rheumatoid arthritis subjects who are prone to develop obstruction of airflow.

Adenosine deaminase activity in rheumatoid pleural effusion

The activity of adenosine deaminase was studied in nine cases of rheumatoid pleural effusion, showing an increase in enzyme activity in all. Rheumatoid arthritis seems unique, however, as it cannot be differentiated from pleural tuberculosis on the basis of this test. Selective increase of adenosine deaminase in both conditions is attributed to stimulation of T lymphocytes in the pleural fluid.

Poor prognosis in patients with rheumatoid arthritis hospitalized for interstitial lung fibrosis

Fifty-seven patients with rheumatoid arthritis (RA) were treated in hospital for diffuse interstitial lung fibrosis. Although interstitial fibrosis (either on the basis of lung function tests or chest roentgenograms or both) is fairly common among patients with RA, according to this study interstitial fibrosis of sufficient extent or severity to warrant hospitalization was rare: incidence of hospitalization due to the lung disease in RA patients was one case per 3,500 patient-years. Eight patients had a largely reversible lung disease associated with drug treatment (gold, D-penicillamine or nitrofurantoin.) The remaining 49 had interstitial fibrosis of unknown cause. Causes for hospitalization were respiratory and general symptoms in 38, but infiltrations on routine chest roentgenographic examinations alone in eleven patients. Forty-five out of the 49 patients had crackles on auscultation. The most typical findings in lung function tests were restriction and a decreased diffusion capacity. These 49 patients showed a poor prognosis, with a median survival of 3.5 years and a five-year survival rate of 39 percent.

HLA-DR4 and pulmonary dysfunction in rheumatoid arthritis

Rheumatoid arthritis is associated with an increased frequency of the B cell alloantigen HLA-DR4, and preliminary work has suggested an association between HLA-DR4 and obstructive lung disease in subjects with rheumatoid arthritis. To prospectively evaluate the influence of HLA-DR4 on pulmonary involvement in patients with rheumatoid arthritis, pulmonary function was measured in four groups of subjects with rheumatoid arthritis in whom HLA-DR4 and smoking status was known: 16 DR4-positive smokers (six current and 10 exsmokers), 16 DR4-negative smokers (six current and 10 exsmokers), eight DR4-positive nonsmokers, and eight DR4-negative nonsmokers. Significant reductions in one-second forced expiratory volume and forced vital capacity were observed in DR4-positive subjects compared with DR4-negative subjects irrespective of cigarette smoking status. In addition, patients with keratoconjunctivitis sicca (secondary Sjögren's syndrome) demonstrated significant reductions in one-second forced expiratory volume, forced vital capacity, and ratio of one-second forced expiratory volume to forced vital capacity compared with those patients without evidence of secondary Sjögren's syndrome. It is concluded that the presence of the HLA-DR4 antigen and secondary Sjögren's syndrome are associated with abnormal pulmonary function in patients with rheumatoid arthritis.

Rheumatoid arthritis with pleural effusion includes a subgroup with autoimmune features and HLA-B8, Dw3 association

Twenty-eight patients with rheumatoid pleural effusion were investigated to examine the frequency of HLA antigens as compared with 56 rheumatoid arthritis (RA) patients without this intrathoracic manifestation of RA and with 283 healthy controls. HLA-B8 was strongly associated with the presence of pleural effusion (PE) in RA patients. A high prevalence (71%) of B8/Dw3 was found among male RA patients of the PE group in whom the joint disease had begun at an age over 50 years and who also had besides pleuritis other intrathoracic manifestations of RA associated with high rheumatoid factor titres and low complement (C4) levels in sera. Actually, the HLA-B8 association was not seen in the rest of the PE group. The finding may be related to the heterogeneity of RA, a male subgroup of the disease being characterized by multiple intrathoracic manifestations and genetically associated with the large group of autoimmune disorders, such as SLE, characterized by high prevalences of HLA-B8 and D(R)3.

Characteristic and specific histological findings in rheumatoid pleurisy

The histological findings in rheumatoid pleuritis (RP), as seen in thoracoscopical biopsies, are found to be: A slightly inflamed stroma with a wave-like surface due to vessel-containing flattened papillae. The surface is covered by layers of pseudostratified epithelioid cells and scattered multinucleated giant cells, layers that easily detach as membranes, leaving the stroma surface "naked". These findings, in combination with the absence of mesothelial cell covering, are viewed as characteristic and specific, as based on a blind review of 17 pleural biopsies from RP patients and 14 biopsies from a control group.