IDIOPATHIC PLEURAL EFFUSIONS AND RHEUMATOID LUNG

Melissa Mattison, M.D. Januar !", !##$ Me%&anis' o( Pleural Flui) A%%u'ulation* stea) state o( +leural (lui) (or'ation an) rea,sor+tion is altere), su%& t&at 'ore (lui) is +ro)u%e) or less is resor,e) -or ,ot&.. In%rease) (lui) entr * in%rease in +er'ea,ilit or 'i%ro/as%ular +ressure %&an0in0 t&e ,alan%e o( & )rostati% an) os'oti% (or%es a%ross t&e se'i+er'ea,le 'e',rane o( t&e 'i%ro/essels. De%reases in +leural +ressure or +las'a os'oti% +ressure %an also in%rease (lui) entr . De%rease) (lui) e1it* Due to intrinsi% (a%tors -e.0., en)oto1in (or'ation, en)o%rine a,nl su%& as & +ot& roi)is', in2ur )ue to 3RT, %&e'ot&era+ , in(iltration o( l '+&ati%s, anato'i% a,nl. or e1trinsi% (a%tors -e.0., e1trinsi% l '+&ati% %o'+ression, su%& as in +ul'onar (i,rosis, li'itation o( res+irator 'otion, )e%rease) intra+leural +ressure, in%rease) s ste'i% /enous +ressure. Dia0nosis 4 a%%o'+lis&e) , +leural (lui) anal sis. In)i%ation (or t&ora%entesis is an ne5 +leural e((usion. Lights Criteria 4 i( an one o( t&e t&ree are +resent, it6s an e1u)ates* o Pleural Flui) -PF. +rotein7Seru' +rotein ratio 8 #.9 o PF LDH7Seru' LDH 8 #.: o PF LDH 8 !7$ u++er li'its o( nor'al o( t&e seru' LDH Transudate ; )ue to i',alan%e o( & )rostati% an) on%oti% +ressure Exudate ; %ause) , +leural an) lun0 in(la''ation or i'+aire) l '+&ati% )raina0e -eit&er 5a lea)in0 to an in%rease in +rotein in t&e +leural s+a%e.. Para+neu'oni% E((usion 4 o%%urs in t&e settin0 o( +neu'onia -o%%urs in "#< o( +atients a)'itte) 5it& +na.. Di/i)e) into uncomplicated, complicated and thoracic empyema I)io+at&i% Pleural E((usion =$>!#< o( +atients 5it& +leural e((usion &a/e no o,/ious %ause )es+ite an e1&austi/e 5or?>u+. Contro/ers e1ists o/er o+ti'al 'ana0e'ent -i.e., %onser/ati/e /ersus 'ore in/asi/e.. In t&e +ast, i( a +atient &a) a +ositi/e PPD an) an @i)io+at&i%A +leural e((usion, anti>TB t&era+ 5as re%o''en)e). Ho5e/er, 'ore re%ent )ata su00ests t&at i( t&e a)enosine )ea'inase le/el is not ele/ate), t&is is not 5arrante). o In (a%t, in a +ros+e%ti/e stu) o( "# +atients 5it& i)io+at&i% +leural e((usion, 'ean a0e 9C, (ollo5e) (or =# ears, e((usions resol/e) in a 'ean ti'e o( 9.: 'ont&s. $! %ases -C#<. &a) no i)enti(ia,le %ause. $ +atients &a) as,estos>relate) e((usions, one ea%& 5it& t&e (ollo5in0* +ul'onar a)eno%ar%ino'a, 'esot&elio'a, &e+ati% %irr&osis, %on0esti/e &eart (ailure an) r&eu'atoi) art&ritis. TB 5as not (oun) in an o( t&e +atients )es+ite a +ositi/e PPD in =D o( t&e +atients. -Note* ADA le/els 5ere not ele/ate) in an o( t&e "# +atients enrolle) in t&e stu) .. Diagnostic approach to an e((usion ,e0ins 5it& t&ora%entesis an) )eter'ination o( transu)ate /s. e1u)ate. I( e1u)ate, see i( etiolo0 is %lear, su%& t&at AFB, % tolo0 , in(e%tion, eso+&a0eal ru+ture et% are %onsi)ere). I( no )ia0nosis et, %onsi)er Pul'onar E',olis' as %ause. I( still no )ia0nosis, +ro%ee) to nee)le ,io+s o( t&e +leura. C&e%? (or AFB, %ulture o( TB et%, rule out 'ali0nan% . I( still not )ia0nosti%, %onsi)er t&ora%os%o+ or o+en +leural ,io+s . R&eu'atoi) Art&ritis De(inition* Pro0ressi/e, s ste'i%, autoi''une +ro%ess %&ara%teriEe) , %&roni% s ''etri%al erosi/e s no/itis F7> nonarti%ular 'ani(estations -e.0., su,G no)ules, /as%ulitis, +eri%ar)itis, 'ononeuritis 'ulti+le1, e+is%leritis, +leural or +ul' a,nl. In%i)en%e #.!>#.$7=### +erson ears, risin0 in%i)en%e 5it& in%reasin0 a0e, u+ until H#6s Male to (e'ale ratio =*! to =*" Criteria for Diagnosis: Need at least 4 of the following: =. Mornin0 sti((ness -lastin0 8 = &our. !. Art&ritis -so(t>tissue s5ellin0 or (lui). o( $ or 'ore 2oints -PIP, MCP, 5rist, el,o5, an?le, MTP 2oints. $. Art&ritis o( &an) 2oints -s5ellin0 o( at least one 5rist, MCP or PIP 2oint. ". S ''etri% art&ritis 9. R&eu'atoi) No)ules :. Seru' RF +ositi/it H. Ra)io0ra+&i% &an) or 5rist %&an0es t +i%al o( RA Generall , =>! ears ,et5een s '+to' onset an) )ia0nosis. S '+to's o(ten start out in a non>s+e%i(i% (as&ion 5it& (ati0ue, 0eneraliEe) 5ea?ness, anore1ia, /a0ue 'us%ulos?eletal s '+to's an) e/entuall s no/itis. =#< o( +atients +resent a%utel 5it& a 'ore (ul'inant s '+to'atolo0 5it& ra+i) )e/elo+'ent o( +ol art&ritis an) ot&er %onstitutional s '+to's, in%lu)in0 (e/er, l '+&a)eno+at& , s+leno'e0al .

Bet& Israel Dea%oness Me)i%al Center Resi)ents6 Re+ort

Extraarticular Lung Manifestations 4 %an ,e )i((i%ult to )i((erentiate (ro' in(e%tion se%on)ar to i''unosu++ression, o/erla++in0 %lini%al s n)ro'e or 'e)i%al %on)ition, )ru0>relate) )isease (ro' si)e e((e%t o( )ru0s use) to treat RA. E+i)e'iolo0 4 )i((i%ult to esti'ate, ,ut Interstitial Lun0 Disease an) +leural )isease are +ro,a,l t&e 'ost %o''on. Interstitial Lung Disease (ILD) 4 'ost %o''on 'ani(estation o( r&eu'atoi) lun0 )isease. RA>ILD is /er si'ilar to i)io+at&i% +ul'onar (i,rosis -IPF.. More %o''on in +atients 5it& se/ere RA. RA>ILD %an ,e as '+to'ati%. S'o?in0 is a ris? (a%tor. ILD ,e%o'e s '+to'ati% as t&e )isease se/erit 5orsens. RA> ILD usuall +ost>)ates t&e onset o( 2oint s '+to's , u+ to 9 ears, ,ut it %an o%%asionall +re%e)e 2oint )isease. S '+to's are usuall insi)ious at onset -e.0., DOE, non+ro)u%ti/e %ou0&, (e/er, %&est +ain.. P& si%al (in)in0s -i.e., ,i,asilar rales, %lu,,in0, si0ns o( +ul'onar & +ertension an) res+irator (ailure. are o(ten onl e/i)ent late in t&e %ourse o( t&e illness. o Bio+s 4 t +i%al &istolo0i%al (in)in0s in%lu)e Usual Interstitial Pneu'onitis -UIP., Nons+e%i(i% Interstitial Pneu'onitis -NSIP., L '+&o% ti% Interstitial Pneu'onitis -LIP., DesIua'ati/e Interstitial Pneu'onitis -DIP. o I'a0in0 (in)in0s* C3R 4 ,i,asilar al/eolar o+a%ities, reti%ulono)ular s&a)o5in0, &one %o',in0 HRCT 4 &i0& res CT 4 s&o5s a,nl sooner t&an C3R, an) 5ill re/eal a ran0e o( +aren%& 'al a,nl, in%lu)in0 ,on%&ie%tasis or ,ron%&iole%tasis 5it&out (i,rosis, 0roun) 0lass attenuation, nonse+tal linear attenuation, &one %o',in0 Pleural Disease 4 /er %o''on ,ut usuall su, %lini%al, 'ale +re)o'inan%e. Auto+s stu)ies esti'ate (reIuen% o( +leural )isease to ,e $C>H$< ,ut onl !=< o( +atients %7o +leuris -as )o =!< o( %ontrols.. Pleural )isease o(ten %oe1ists 5it& r&eu'atoi) no)ules an) ILD in $#< o( +atients. Onl 9< &a/e ra)io0ra+&i% e/i)en%e o( e((usion, t&us t&e are usuall s'all 'o)erate in siEe, an) unilateral. Usuall o%%urs in +atients 5it& lon0>stan)in0 &istor o( r&eu'atoi) art&ritis, ,ut may +re)ate t&e )ia0nosis. o S '+to's* C&est +ain, an)7or (e/er. D s+nea i( lar0e enou0& o( an e((usion o T&ora%entesis* t +i%al (in)in0s in%lu)e* o J,% K 9###7''$ o o o o o o o o Serous to a 'il? >0reen a++earan%e Protein 8 $ 07)L -e1u)ate. Glu%ose K 9 ''ol LDH 8 =### U7'L +H H RF 8 =*$!# Co'+le'ent ; lo5 C tolo0 %ell L K 9###7''$

%ell t +e * l '+&o% tes -neutro+&ils an) eos a%utel . an) t&e @RA %ellA -neutro+&il 5it& in%lusion ,o)ies. o Mana0e'ent* t&ora%entesis to )ia0nose t&e e((usion an) rule out ot&er +ro%ess -i.e., in(e%tion, 'ali0nan% .. S '+to'ati% +leuritis an) e((usions (ro' RA 0enerall resol/e s+ontaneousl o/er 'ont&s, ,ut initial treat'ent in%lu)es NSAIDs -in)o'et&a%in.. Can also %onsi)er s ste'i% %orti%osteroi)s or e/en intra+leural %orti%osteroi)s Bronchiolitis Obliterans Organizing Pneu onia (BOOP) 4 +atients 5it& RA 5&o )e/elo+ BOOP +resent 5it& %ou0&, ) sn+ea, 'alaise, 5ei0&t loss an) (e/er. Dia0nosis t +i%all 'a)e 5it& trans,ron%&ial or t&roa%os%o+i% lun0 ,io+s . Other * O,literati/e ,ron%&iolitis, Folli%ular ,ron%&iolitis, Mas%uliltis, No)ules

Bet& Israel Dea%oness Me)i%al Center Resi)ents6 Re+ort