Isolated Recurrent Pleural Effusions in a Patient With Rheumatoid Arthritis in Remission for Nine Years: A Case Report

The development of pleural effusion in patients with active rheumatoid arthritis is a relatively common entity, yet it is uncommon in patients without clinical arthritis and other clinical features of disease flare-ups. This case report describes a 58-year-old patient with rheumatoid arthritis treated with sulfasalazine who developed recurrent large pleural effusion without clinical arthritis, after being in remission for nine years. Laboratory results showed neutrophilic leukocytosis, along with elevated inflammatory markers. Fluid analysis was suggestive of sterile exudative fluid, and 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. Chest X-ray showed right-sided pleural effusion, with underlying atelectasis. The clinical intervention included thoracentesis, piperacillin-tazobactam 4g q8 hr., prednisolone 10 mg, and sulfasalazine 1.5g. Upon hospital discharge, he was prescribed oral prednisolone 5 mg for two days, and colchicine 0.5 mg daily. After seven days, he presented with a recurrence of his symptoms and an X-ray revealed a new right-sided large pleural effusion. On the second admission, sulfasalazine was suspended, and he was switched to methotrexate. A remarkable improvement in the patient's condition was noted with an unremarkable X-ray and remained stable three months post-discharge on his following appointments as well. This report necessitates the need for the early diagnosis of a rheumatoid arthritis flare-up and the appropriate timely switch to the disease-modifying agent for better disease control.