An account of pleural effusions, pulmonary nodules and cavities attributable to rheumatoid disease.

Nine case histories and references to published reports are used to illustrate the manifestations and management of pleural effusions, lung nodules and lung cavities which may occur in cases of rheumatoid disease. Repeated aspiration of effusions seldom is useful. They often are chronic and symptomless. What is taking place in some turbid and purulent effusions is debatable, since there can be an associated leucocytosis without infection. In the presence of acute symptoms, such as rigors, careful evaluation of such effusions is required, since there have been fatal examples with rather uncertain bacteriological findings. Lung nodules ordinarily cause a radiographic blemish without symptoms but may predispose to small haemoptyses or may rupture into the pleural cavity to cause a pneumothorax, usually requiring surgical resection of the nodule, whether or not a pleural effusion is present. Some nodules and lung cavities do not have the histology of the typical necrobiotic nodule but it is unlikely that they are fundamentally different. Large cavitated lung lesions which closed on azothioprine treatment are described, together with similar untreated cavities which became secondarily infected with a fatal outcome. It is suggested that the history of possible rheumatoid disease, even of 'aches and pains' must be sought if this aetiology for pleural effusions, lung nodules and unusual lung cavities is not to be overlooked, with the penalty of diagnostic thoracotomy or wrong treatment for the patient.