A 48-year-old man was transferred to our hospital because of persistent.

A 48-year-old man was transferred to our hospital because of persistent, massive bilateral pleural effusions and dyspnea. He had been in his usual state of virtuous health until 2 weeks prior to admission, when he exhibited fever, chills, myalgias, and a sore throat. upon admission to the other hospital, bilateral pleural effusions were noted. Despite multiple drainage conducts the effusions reaccumulated and persisted.

Physical Examination

Vital signs: temperature, 389 [degrees] C; pulsation 110/min; respirations, 40/min; BP, 140/80 mm Hg General: diaphoretic, nontoxic condition. Lymph nodes: no adenopathy. Chest: dullnes to percussion and decreased breath wholes at both bases; bronchial breath perfects in left midlung field with egophony Cardiac: regular tachycardia. Joints: normal. Skin: no lesions.

Laboratory Findings

WBC 8200 with 75 percent neutrophils, 7 percent bands, 12 percent lymphocyte and 6 percent monocytes; erythrocyte sedimentation rate (Westergren), 97 mm/h Antinuclear antibody proof negative. Rheumatoid factor (RF): 1:2560 Chest radiograph: (Fig 1) Pleural fluid analysis of specimen obtained from right thoracentesis: appearance, fulvid hazy; nucleated cells: 850/[mm.sup.3]; differential, 96 percent portioned neutrophils, 2 percent lymphocytes, 2 percent monocytes; RBC 5530/[mmup3]; total protein, 34 g/dl (normal, 42 g/dl); lactate dehydrogenase (LDH) 3440 U/L (normal, 189 U/L); diabetic sugar 7 mg/dl (normal, 134 mg/dl); pH 677; cytology, negative for malignancy; Gram stain and agriculture negative. Findings from pleural fluid analysis of the specimen obtained from left thoracentesis were similar to those in the specimen obtained upon the right. Percutaneous pleural biopsy showed granulation tissue with acute inflammatory exudate.

What should be the nearest diagnostic test? What is the greatest in number likely diagnosis?

Diagnostic test: Review of pleural fluid cytology

Diagnosis: Rheumatoid pleurisy

The differential diagnosis of a pleural effusion with soft pH, low glucose, and high LDH values includes bacterial empyema, paragonimiasis, tuberculosis, malignancy, and rheumatoid pleuritis. Cytologic analysis of pleural fluid can be helpful and, in this case, was diagnostic for rheumatoid pleuritis when granular amorphous material and elongated macrophages were demonstrated (Fig 2) These findings describeed two of the three unique and pathognomonic cytologic features described in rheumatoid pleural effusions. The full cytologic triad consists of elongated macrophages, giant multinucleated macrophages, and a background of granular necrotic debris; these cellular features are similar to the histologic findings in rheumatoid synovitis, granulomatous rheumatoid pleuritis, and subcutaneous nodules.

Nosanchuk and Naylor initially described the diagnostic triad, which they ascribed to exfoliation of pleural constitutings from regions of granulomatous rheumatoid pleuritis. Thoracoscopy has shown that the pleural surface in rheumatoid pleuritis appears "gritty" and thickened with numerous small granules, about 05 mm in diameter. The appearance of the parietal pleura upon microscopic examination resembles an "opened-out" rheumatoid nodule with its three composing layers parallel to the pleural surface. These layers include fibrinoid necrosis in succession the surface, palisading elongated solitary abode; squalids and granulation tissue with cellular infiltration including giant confined apartments This inflammatory covering is easily detached from the pleural surface, which may explain the high frequent occurrence of nondiagnostic blind pleural biopsies in patients with rheumatoid pleurisy

In their series, Nosanchuk and Naylor set that 24 patients who had a certain number of or all of these cytologic features in their pleural fluid had rheumatoid arthritis; simply half of the patients exhibited all 3 constituents and 5 had only granular material. Faursehou et al reported upon the cytologic analysis of pleural fluid taken during 1200 thoracoscopy procedures; 9 specimens demonstrated the triad, and all 9 were from patients who had rheumatoid arthritis. Interestingly, 1 of the 9 patients in the latter series had normal serum and pleural fluid grape-sugar Therefore, it appears that the specificity of the cytologic findings is high, if it be not that no assessment of sensitivity can be made based onward the data from existing series.

Other cytologic changes have been observ in rheumatoid pleural effusions if it be not that are nondiagnostic. Mesothelial cells were noticeably absent from 23 of 24 pleural fluid specimens in the largest series to date. Elevated pleural rheumatoid factor and "RA cells" (ragocytes, which are leukocyte with small, spherical cytoplasmic inclusions) have been plant in other diseases. Cholesterol crystals may be observ and likely mirror the chronic nature of the fluid.

In the at hand patient, because of the high serum rheumatoid factor on a level the extremely low pleural fluid starch-sugar concentration, and the absence of an identifiable infectious or malignant cause of the effusions, a presumptive diagnosis of rheumatoid pleurisy was made. The features of his presentation that were les typical for, however not inconsistent with, rheumatoid pleurisy were the storm of pleural effusions prior to arthritis (<7 percent of cases), bilateral effusions (about 25 percent of cases), and massive effusions (rare). following review of his pleural fluid cytology confirmed the diagnosis of rheumatoid pleurisy by dint of demonstrating granular amorphous material and elongated macrophages.

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