[Rheumatoid nodule diagnosed by thoracoscopy using flexible fiberoptic bronchoscope]

Area of Science:

• Rheumatology
• Pulmonology
• Pathology

Background:

• Rheumatoid arthritis (RA) can present with diverse extra-articular manifestations.
• Rheumatic pleurisy is a less common pleural complication of RA, often challenging to diagnose.
• Distinguishing rheumatic pleurisy from other pleural effusions, such as tuberculous pleurisy, is critical for appropriate management.

Observation:

• A 51-year-old male patient with a history of RA presented with right-sided chest pain and pleural effusion.
• Elevated rheumatoid factor (RF) in serum and pleural fluid suggested rheumatic etiology, but high adenosine deaminase levels raised suspicion for tuberculosis.
• Thoracoscopy revealed sporadic bluish-white nodular lesions on the pleura.

Findings:

• Pathological examination of pleural nodules showed granuloma formation with palisade giant cells, consistent with rheumatoid nodules.
• These findings confirmed the diagnosis of rheumatic pleurisy.
• Treatment with increased-dose prednisolone resulted in rapid resolution of the pleural effusion.

Implications:

• Thoracoscopy is a valuable diagnostic tool for identifying rheumatoid nodules in cases of suspected rheumatic pleurisy.
• Prompt diagnosis and immunosuppressive therapy can effectively manage rheumatic pleurisy.
• This case underscores the importance of considering rheumatic pleurisy in RA patients with unexplained pleural effusions.