Rheumatoid arthritis (RA) is a systemic illness where the development of pulmonary nodule has been described in from 4 to 20% of patients. Symptomatic pleural manifestations occur in 3 to 5% of cases. Rarely, pulmonary nodules become necrotic and lead to pleural complications. Bilateral pneumothorax has only rarely been described.
We report the case of a 64-year-old woman, who had been treated for RA for several years and presented with bilateral pneumothorax secondary to necrobiosis of one or several pulmonary rheumatoid nodules. The management of the pneumothorax was very prolonged and difficult, and despite surgical pleurodesis, the lung did not reexpand fully. Pathological examination of the pleura revealed a noncaseating granulomatous pattern. The diagnosis of a sarcoidosis like disease, possibly induced by anti-TNFα, or of pleural tuberculosis were suggested, but we concluded that the final diagnosis was of pleural rheumatoid involvement.
Bilateral pneumothorax secondary to rheumatoid nodule is a rare entity. The management of such a complication is difficult, particularly in patients who receive an immunosuppressant regimen. A granulomatous pattern has been described rarely in the pleural tissue of these patients. Specific RA pleural involvement has to be taken in consideration when other diagnoses are eliminated, especially tuberculosis or sarcoidosis-like disease.