Therapeutic options for refractory massive pleural effusion in systemic lupus erythematosus: a case study and review of the literature

Deciphering the puzzle: a case report of Tjalma syndrome (pseudo-pseudo Meigs' syndrome) with profoundly elevated CA-125 and pleural effusion

Elevated CA-125 levels, polyserous effusions (such as pleural effusion, ascites, etc.) in young women with systemic lupus erythematosus (SLE) may signal pseudo-pseudo Meigs' syndrome (PPMS), after excluding other causes. We describe a 32-year-old SLE patient with recurrent bilateral pleural effusions and unexplained hypercalcemia for 10 months. Extensive evaluations revealed no infections or tumors. Cytokine analysis showed elevated interleukin (IL) levels, especially IL-6 in pleural effusion. Treatment with immunosuppressive therapy resulted in reduced cancer antigen (CA) 125 levels and decreased effusion volume, demonstrating a positive response to intervention in this case of PPMS.

Systemic lupus erythematosus presenting as right-sided massive pleural effusion with autoimmune hypothyroidism and medium vessel vasculopathy

Segmental involvement of medium-sized vessels are lesser-known manifestations of systemic lupus erythematosus (SLE) vasculopathy. Medium vessel vasculopathy and peripheral vascular disease (PVD) mimicking manifestations of SLE, although rare, have been reported, particularly in Asian women mostly under the age of 30 years. This is due to metabolic disadvantages in their ethnicity, with high incidence of insulin resistance and resulting metabolic syndrome, leading to lower high-density lipoprotein cholesterol levels, higher triglyceride levels and small dense low-density lipoprotein, increased proinflammatory cytokines, endothelial dysfunction and procoagulant tendency. Owing to the longer duration of the disease with the simultaneous use of steroids, vessels are often affected. SLE may also present with thyroid manifestations against a background of a proinflammatory immune state, where autoimmune thyroid diseases, such as Hashimoto's thyroiditis, may coexist. Here, we describe the case of a young woman who presented with progressive shortness of breath, right leg pain and cough with amenorrhoea and was diagnosed with SLE.

Systemic Lupus Erythematosus and Lung Involvement: A Comprehensive Review

Systemic lupus erythematosus (SLE) is a complex autoimmune disease with multiorgan manifestations, including pleuropulmonary involvement (20-90%). The precise mechanism of pleuropulmonary involvement in SLE is not well-understood; however, systemic type 1 interferons, circulating immune complexes, and neutrophils seem to play essential roles. There are eight types of pleuropulmonary involvement: lupus pleuritis, pleural effusion, acute lupus pneumonitis, shrinking lung syndrome, interstitial lung disease, diffuse alveolar hemorrhage (DAH), pulmonary arterial hypertension, and pulmonary embolism. DAH has a high mortality rate (68-75%). The diagnostic tools for pleuropulmonary involvement in SLE include chest X-ray (CXR), computed tomography (CT), pulmonary function tests (PFT), bronchoalveolar lavage, biopsy, technetium-99m hexamethylprophylene amine oxime perfusion scan, and (18)F-fluorodeoxyglucose positron emission tomography. An approach for detecting pleuropulmonary involvement in SLE includes high-resolution CT, CXR, and PFT. Little is known about specific therapies for pleuropulmonary involvement in SLE. However, immunosuppressive therapies such as corticosteroids and cyclophosphamide are generally used. Rituximab has also been successfully used in three of the eight pleuropulmonary involvement forms: lupus pleuritis, acute lupus pneumonitis, and shrinking lung syndrome. Pleuropulmonary manifestations are part of the clinical criteria for SLE diagnosis. However, no review article has focused on the involvement of pleuropulmonary disease in SLE. Therefore, this article summarizes the literature on the epidemiology, pathogenesis, diagnosis, and management of pleuropulmonary involvement in SLE.

Successful treatment of recurrent pleural and pericardial effusions with tocilizumab in a patient with systemic lupus erythematous

A 22-year-old Caucasian man presented to hospital with pleuritic chest pain. He had had a history of a sun-sensitive rash a year prior. Workup revealed normal cardiac enzymes and chest X-ray. However, electrocardiogram revealed ST elevation and PR depression, and echocardiogram revealed a slight pericardial effusion without other findings. A diagnosis of pericarditis was made. Subsequently, he was found to be positive for antinuclear antibodies (ANAs), as well as antibodies to SSA, SSB and double-stranded DNA; C3 was low, and C4 was undetectable. A diagnosis of systemic lupus erythematosus was made. The patient initially responded to high-dose ibuprofen. One month later, he developed a new pericardial effusion, this time with concomitant massive left-sided pleural effusion, requiring three separate thoracenteses draining a total of 6 L of pleural fluid. The recurrent effusion failed to respond to high-dose corticosteroid treatment. Owing to the severity and rapidity of the recurrence of pleural and pericardial effusion, intravenous tocilizumab was administered. The patient had excellent clinical and radiographic improvement. This case shows that tocilizumab may have a role in the treatment of intractable pleuropericardial effusion and other forms of lupus-associated serositis.

Intrapleural corticosteroid injection in eosinophilic pleural effusion associated with undifferentiated connective tissue disease

Eosinophilic pleural effusion (EPE) is defined as a pleural effusion that contains at least 10% eosinophils. EPE occurs due to a variety of causes such as blood or air in the pleural space, infection, malignancy, or an autoimmune disease. Undifferentiated connective tissue disease (UCTD) associated with eosinophilic pleural effusion is a rare condition generally characterized by the presence of the signs and symptoms but not fulfilling the existing classification criteria. We report a case involving a 67-year-old man with UCTD and EPE, who has been successfully treated with a single intrapleural corticosteroid injection.

Sterile empyematous pleural effusion in a patient with systemic lupus erythematosus: a diagnostic challenge

Herein we present a case of a patient with systemic lupus erythematosus (SLE) and a sterile empyematous pleural effusion, a complication not generally associated with SLE. A discussion of the diagnostic and treatment dilemmas follows the case presentation.