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Wang D, Zhang J, Lau J, Wang S, Taneja V, Matteson EL, Vassallo R. Mechanisms of lung disease development in rheumatoid arthritis. Nat Rev Rheumatol 2019; 15:581-596. [PMID: 31455869 DOI: 10.1038/s41584-019-0275-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2019] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Dan Wang
- Department of Rheumatology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jie Zhang
- Division of Pulmonary Medicine, Department of Medicine, Chongqing General Hospital, Chongqing, China
| | - Jessica Lau
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Shaohua Wang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Veena Taneja
- Department of Immunology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Eric L Matteson
- Division of Rheumatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA. .,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA.
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Pseudochylothorax Combined with Spontaneous Pneumothorax: Case Report of a Rare Complication of Rheumatoid Arthritis. Case Rep Med 2018; 2018:7846962. [PMID: 29849661 PMCID: PMC5937586 DOI: 10.1155/2018/7846962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 03/08/2018] [Accepted: 03/26/2018] [Indexed: 11/23/2022] Open
Abstract
Pleural involvement is the most frequent thoracic complication of rheumatoid arthritis (RA), usually occurring in patients with known RA. Typical rheumatoid pleural effusion is an exudate characterized by low pH and glucose levels and high LDH activity. Rarely, it has features of pseudochylothorax. Other uncommon complications are pneumothorax, hydropneumothorax, empyema, and bronchopleural fistula. The case of a 51-year-old man with a spontaneous, small, and asymptomatic hydropneumothorax with features of pseudochylothorax is presented. After careful clinical and laboratory evaluation, he was diagnosed with rheumatoid arthritis, and we admitted that the pleural changes were secondary to the connective tissue disease. He started immunosuppressive treatment and maintained stability during follow-up, without need of specific pleural treatment. We hypothesized that the pleural nodule found on the chest computed tomography scan was related with the simultaneous occurrence of pleural effusion and pneumothorax. This is a rare presentation and complication of RA, highlighting the utility of a comprehensive clinical and laboratory evaluation and focusing on the importance of pleural rheumatoid nodules in the pathogenesis of RA pleural disease.
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Lama A, Ferreiro L, Toubes ME, Golpe A, Gude F, Álvarez-Dobaño JM, González-Barcala FJ, San José E, Rodríguez-Núñez N, Rábade C, Rodríguez-García C, Valdés L. Characteristics of patients with pseudochylothorax-a systematic review. J Thorac Dis 2016; 8:2093-101. [PMID: 27621864 DOI: 10.21037/jtd.2016.07.84] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Pseudochylothorax (PCT) (cholesterol pleurisy or chyliform effusion) is a cholesterol-rich pleural effusion (PE) that is commonly associated with chronic inflammatory disorders. Nevertheless, the characteristics of patients with PCT are poorly defined. METHODS A systematic review was performed across two electronic databases searching for studies reporting clinical findings, PE characteristics, and the most effective treatment of PCT. Case descriptions and retrospective studies were included. RESULTS The review consisted of 62 studies with a total of 104 patients. Median age was 58 years, the male/female ratio was 2.6/1, and in the 88.5% of cases the etiology was tuberculosis (TB) or rheumatoid arthritis (RA). PE was usually unilateral (88%) and occupied greater than one-third of the hemithorax (96.3%). There was no evidence of pleural thickening in 20.6% of patients, and 14 patients had a previous PE. The pleural fluid (PF) was an exudate, usually milky (94%) and with a predominance of lymphocytes (61.1%). The most sensitive tests to establish the diagnosis were the cholesterol/triglycerides ratio (CHOL/TG ratio) >1, and the presence of cholesterol crystals (97.4% and 89.7%, respectively). PF culture for TB was positive in the 34.1% of patients. Favorable outcomes with medical treatment, therapeutic thoracentesis, decortication/pleurectomy, pleurodesis, thoracic drainage and thoracoscopic drainage were achieved in 78.9%, 47.8%, 86.7%, 66.6%, 37.5% and 42.9%, respectively. CONCLUSIONS PCT is usually tuberculous or rheumatoid, unilateral and the PF is a milky exudate. The presence of cholesterol crystals and a CHOL/TG ratio >1 are the most sensitive test for the diagnosis. The lack of pleural thickening does not rule out PCT. Treatment should be sequential, treating the underlying causes, and assessing the need for interventional techniques.
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Affiliation(s)
- Adriana Lama
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain
| | - Lucía Ferreiro
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain;; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
| | - María E Toubes
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain
| | - Antonio Golpe
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain;; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
| | - Francisco Gude
- Unidad de Epidemiología Clínica, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain;; Grupo Epidemiología de Enfermedades Frecuentes, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
| | - José M Álvarez-Dobaño
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain;; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
| | - Francisco J González-Barcala
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain;; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
| | - Esther San José
- Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain;; Servicio de Análisis Clínicos, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain
| | - Nuria Rodríguez-Núñez
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain
| | - Carlos Rábade
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain
| | - Carlota Rodríguez-García
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain
| | - Luis Valdés
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, Spain;; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, Spain
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Tanaka N, Kusunoki Y, Kaneko K, Yamamoto T, Kaburaki M, Muraoka S, Abe H, Endo H, Sato D, Homma S, Shibuya K, Kawai S. Systemic lupus erythematosus complicated by recurrent pneumothorax: Case report and literature review. ACTA ACUST UNITED AC 2010; 33:162-8. [PMID: 20601838 DOI: 10.2177/jsci.33.162] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pneumothorax is a rare pleuropulmonary manifestation of systemic lupus erythematosus. We encountered a 37-year-old Japanese woman who had systemic lupus erythematosus complicated by recurrent pneumothorax during treatment for recurrent serositis with glucocorticoid therapy. She was admitted for the third episode of lupus peritonitis in December 2005. Intravenous cyclophoshamide and increased dose of oral prednisolone were administered. In early January 2006, hemoptysis was observed and bronchofiberscopy revealed hemorrhage from the left lower lobe. After intravenous methylprednisolone pulse therapy and oral cyclosporine therapy were added, pleurisy and pulmonary hemorrhage improved. On February 22nd, she suddenly developed pneumothorax on the right side, followed by pneumothorax on the left side after 2 days. This pneumothorax on the left side did not improve despite chest tube drainage for over one month. She underwent thoracoscopic partial lobectomy of lower lobe of the left lung, and her symptoms improved. Review of the literature identified 10 case reports of systemic lupus erythematosus complicated by pneumothorax. All of the patients including our case had underlying pulmonary lesions, and 9/11 patients had pleurisy. Besides 10/11 patients received glucocorticoid therapy before the occurrence of pneumothorax. Tissue fragility caused by these factors might contribute to the complication of pneumothorax in patients with systemic lupus erythematosus.
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Affiliation(s)
- Nahoko Tanaka
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine
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Abstract
Although connective tissue diseases may have similar radiographic appearances, a variety of pathologic processes can be seen in the lung of these patients. In such circumstances, early recognition of lung involvement is now easily demonstrated by imaging methods. The development of thin-section and dynamic CT techniques has significantly improved diagnostic accuracy. Moreover, expiratory HRCT is a helpful technique in demonstrating air trapping in these patients. The radiologist plays a significant role in the evaluation of pulmonary manifestations of connective tissue diseases.
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Affiliation(s)
- T Franquet
- Chest Imaging Section, Department of Diagnostic Radiology and Radiology, Hospital de Sant Pau, Universitat Autónoma de Barcelona, Spain.
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Abstract
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.
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Affiliation(s)
- L T Tanoue
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
Spontaneous pneumomediastinum has not been reported in adult polymyositis or dermatomyositis, either in conjunction with spontaneous pneumothorax or in isolation. Spontaneous pneumothorax has been rarely reported as a complication of rheumatoid arthritis, systemic lupus erythematosus, scleroderma, and childhood dermatomyositis. It is associated with active, progressive pulmonary involvement and a poor prognosis. We describe an adult with dermatomyositis and spontaneous pneumomediastinum with a favourable outcome.
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