N'Gabou D, Magdeleinat P, Weber N, Raynaud C, Gossot D, Mechouek A, Stern J-B
Département thoracique, institut mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France.
Rev Mal Respir. 2010 Nov;27(9):1119-23. doi: 10.1016/j.rmr.2010.04.015. Epub 2010 Oct 27.
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.
类风湿关节炎（RA）是一种全身性疾病，据描述，4%至20%的患者会出现肺结节。有症状的胸膜表现见于3%至5%的病例。肺结节很少会坏死并导致胸膜并发症。双侧气胸仅有极少的病例报道。
我们报告一例64岁女性患者，她患RA多年，因一个或多个肺类风湿结节坏死而出现双侧气胸。气胸的治疗过程非常漫长且困难，尽管进行了手术胸膜固定术，但肺并未完全复张。胸膜的病理检查显示为非干酪样肉芽肿模式。有人提出可能是由抗TNFα诱导的类结节病或胸膜结核的诊断，但我们得出的结论是最终诊断为胸膜类风湿累及。
类风湿结节继发双侧气胸是一种罕见情况。这种并发症的治疗很困难，尤其是在接受免疫抑制治疗方案的患者中。在这些患者的胸膜组织中很少有肉芽肿模式的描述。当排除其他诊断，尤其是结核病或类结节病样疾病时，必须考虑特异性RA胸膜累及。
