Bilateral pneumothoraces and pleural effusions in rheumatoid lung disease.

Bilateral pneumothoraces and pleural effusions in rheuma-toid lung disease SIR,-I read with interest the report by Dr 0 Ayzenberg and his colleagues entitled "Bilateral pneumothoraces and pleural effusions complicating rheumatoid lung disease" (February 1983, p 159). We encountered this situation in a 60 year old woman with long standing seropositive nodular rheumatoid arthritis admitted to hospital in March 1982. She developed a dry cough a few weeks before this event and in the week before admission experienced two distinct nocturnal episodes of "life threatening breathlessness" without chest pain. The chest radiograph confirmed the diagnosis but neither lung could be re-expanded with prolonged underwater sealed drainage (fig). The necrotising nodular rheumatoid pleuritis (confirmed at surgery and later at necropsy) was too severe and extensive to permit visceral decortication and promote satisfactory expansion of the underlying lung. The patient died three months later from staphylococcal septicaemia, bilateral empyemas, and persistent broncho-pleural fistulae. At least three other cases have now been described 1 2 (including that of Ayzenberg et al), all in men (ages 48, 58, 62) with nodular pleural rheumatoid disease. Two had chronic deforming arthritis, subcutaneous nodules, pulmonary fibrosis, and recurrent unilateral pneumothoraces antedating the bilateral event. In contrast, the youngest had a very short arthritic history with radiographic changes only of periarticular osteoporosis. All required bilateral pleurec-tomy following the failure of underwater seal drainage. This procedure was successful in the two with relatively low ;.6, .: Chest radiograph after prolonged bilateral underwater sealed drainage in a 60 year old woman with longstanding rheumatoid arthritis. titres of circulating rheumatoid factor but failed in the patient with a high latex titre (1/1280) similar to ours. The presence of eosinophilia has been associated with aggressive extra-articular rheumatoid pleuropulmonary disease and pneumothorax,2 but neither of the two who died showed eosinophilia during their illnesses. The persistent presence of rheumatoid factor in high titre may carry prognostic significance in this unusual situation, as it does for articular disease.3 Course and prognosis in rheumatoid arthritis: a further report. SIR,-We read with interest the case report by Dr 0 Ayzenberg and colleagues describing a patient with simultaneous bilateral pneumothoraces and pleural effusions complicating rheumatoid lung disease (February 1983, p 159). The authors claimed that theirs was the first documentation of the simultaneous occurrence of these complications. However Crisp et al have reported a similar case with bilateral pneumothoraces and small pleural effusions.' We would like to call …