On physical examination, the patient was afebrile with temperature of 37 C, Heart rate 77 bpm, tachypneic with respiratory rate of 22br/min, BP 140/84, and O2 saturation of 97% on room air. The patient was alert, oriented, not in acute distress. Respiratory examination revealed: stony dullness on right lower side percussion, decreased air entry in the right side with right basal crepitation. Cardiovascular exam showed: normal S1, S2, no murmurs or added sounds. There was + 3 pitting edema in his left leg extending to above knee level. Edema was associated with mild calf tenderness and negative Homans sign. The patient had no joint tenderness, swelling, or erythema, no rash, no mouth or nasal ulcers, and no lymphadenopathy. A subsequent lab work-up and radiological examination was ordered for the patient (Table 1).
Table 1
Lab tests results for the patient
Variable | Reference range | On admission | On Discharge |
Hemoglobin (g/dl) | 11.6–14.8 | 12.9 | 11.6 |
Hematocrit (L) | 35.1–44.4 | 0.35 | |
White blood cell count (per µl) | 4.5–11.0 | 12.8x10^9/L | 9.4x10^9/L |
Neutrophils (%) | 0.0–2.5 | 83 | 66.7 |
Lymphocytes (%) | 16.5–49.5 | 8.4 | 19.10 |
Monocytes (%) | 2.0–10.0 | 8.2 | 11.10 |
Eosinophil (%) | 0.0–8.5 | 0.20 | 2.70 |
Platelet count (per µl) | 158,000–348,000 | 256,000 | 255,000 |
Sodium (mmol/L) | 135–145 | 138 | 137 |
Potassium (mmol/L) | 3.6–4.8 | 3.6 | 4.3 |
Chloride (mmol/L) | 101–108 | 103 | 100 |
Creatinine (micromol/L) | 61–106 | 113 | 102 |
Urea nitrogen (mmol/L) | 2.80–8.10 | 4.9 | 4.30 |
C-reactive protein (mg/dl) | Normal high < = 5 | 224 | 90 |
ESR | | 64 | 98 |
Laboratory results showed neutrophilic leukocytosis, along with elevated inflammatory markers. ECG and troponin was done to rule out cardiac causes of chest pain which were within normal (Tabe1 1) Fluid analysis was suggestive of sterile exudative fluid. Adenosine Deaminase of pleural fluid was negative. Culture and acid-fast bacilli of pleural fluid were both negative. Fluid cytology did not reveal any malignant cells (Table 2). Chest X-ray showed right-sided pleural effusion, with underlying atelectasis (Fig. 1). CT Thorax w/o contrast post pleural tab (Fig. 2) showed bilateral basal atelectasis, fibrotic bands, minimal right pleural effusion and a trace of pleural effusion on the left side. There was no evidence of chronic lung disease. Pan CT to rule out malignancy returned negative and the CTPE negative.
Table 2
Fluid analysis (Pleural fluid) | Finding |
Appearance | Turbid |
Color | Yellow |
RBC | 4,000 cell/mm3 |
WBC | 11,335 |
Segs | 78 |
Lymphocyte | 14 |
Monocytes | 6 |
Eosinophil | 2 |
Albumin | 23g/L |
Protein | 48 g/L |
Glucose | 1.7 mmol/L |
Urea | 5.4 mmol/L |
LDH | 692 IU/L |
Uric acid | 356 |
Therapeutic Intervention
The patient was initially managed with thoracentesis, Tazocin 4g q8 hr, prednisolone 10mg, and Sulfasalazine 1.5g as case of RA complicated by pleural effusion with possible underlining pneumonia. After this treatment plan, he showed some improvement and was discharged with oral prednisolone 5mg for 2 days, and colchicine 0.5mg daily, as a part of his home medications. After 7 days from discharge, he presented to the emergency department with a recurrence of his symptoms. A repeat X-ray revealed a new right-sided large pleural effusion. He was tapped again, analysis showed exudative pleural effusion. Upon his second admission, sulfasalazine was suspended and he was switched to methotrexate, to achieve better control of his disease. The patient remarkably improved after starting methotrexate and cessation of sulfasalazine. He was seen in the rheumatology clinic two weeks later, on methotrexate 15 mg only, he was feeling well, improved clinically, and his follow-up x-rays showed no recollection. The patient remained stable three months post-discharge on his following appointments as well.