Isolated Recurrent Pleural Effusions in a Patient with Rheumatoid Arthritis in Remission for 9 Years: Case Report

Abstract

Abstract Introduction: The development of pleural effusion in patients with active rheumatoid arthritis is a relatively common entity, yet it is uncommon in patients without clinical arthritis and other clinical features of disease flare up. Clinical Findings: This case report describes a 58 year old patient with rheumatoid arthritis treated with Sulfasalazine who developed recurrent large pleural effusion without clinical arthritis, after being in remission for nine years. Laboratory results showed neutrophilic leukocytosis, along with elevated inflammatory markers. Fluid analysis was suggestive of sterile exudative fluid, and adenosine deaminase of pleural fluid was negative. Culture and acid-fast bacilli of pleural fluid were both negative. Fluid cytology did not reveal any malignant cells. Chest X-ray showed right-sided pleural effusion, with underlying atelectasis. Clinical intervention included thoracentesis, Tazocin 4g q8 hr, prednisolone 10mg, and Sulfasalazine 1.5g. Upon hospital discharge he was prescribed oral prednisolone 5mg for 2 days, and colchicine 0.5mg daily. After 7 days he presented with a recurrence of his symptoms, X-ray revealed a new right-sided large pleural effusion. On second admission, sulfasalazine was suspended and he was switched to methotrexate. Remarkable improvement in the patient condition was noted, with an unremarkable X-ray, and remained stable three months post-discharge on his following appointments as well. Conclusion: This report necessitates the need for early diagnosis of rheumatoid arthritis flare up, and the appropriate timely switch to the disease modifying agent for better disease control.