Letter to the Editor
Vasculitic Pleural Effusion
Derrame pleural vasculítico
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(b) Painful penis ulceration. (c) Microphotography where dense lymphocytic inflammation is observed around the wall of a small vessel in a sample collected from the dermis (H&E, 400×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Making the right and timely diagnosis of systemic vasculitis (SV) is often a challenge, even for the most experienced physicians. The pleural condition produced by SV is usually the result of the underlying lung disease. Endothelial damage produced by the involved inflammatory mechanisms increases capillary permeability to protein and fluid towards the pleural cavity. So far, the characteristics of the pleural fluid resulting from the SV have not been properly defined. We will present the case of a male subject who started having a pleural effusion attributed to SV.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 67-year-old male subject was hospitalised due to one-week course dyspnoea and fever. Upon admission, the patient was in poor general condition and with a SatO<span class="elsevierStyleInf">2</span> of 78% at room temperature. His vital signs were the following: RR 29<span class="elsevierStyleHsp" style=""></span>min, HR 112<span class="elsevierStyleHsp" style=""></span>min, BP 145/85<span class="elsevierStyleHsp" style=""></span>mmHg and a temperature of 37<span class="elsevierStyleHsp" style=""></span>°<span class="elsevierStyleSmallCaps">C</span>. Physical examination showed a right-sided pleural effusion syndrome and very scarce fine crackles in the left hemithorax. The chest X-ray and computed tomography showed bilateral alveolar opacities and verified the presence of a right-sided pleural effusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Laboratory results only showed leukocytosis of 21,400<span class="elsevierStyleHsp" style=""></span>cells/μL, out of which 9400<span class="elsevierStyleHsp" style=""></span>cells/μL corresponded to lymphocytes. The patient showed no increased nitrogen compounds, and the general urinalysis showed no signs of sediment or proteinuria. In thoracentesis, a thick yellow fluid was obtained with a pH 7.0; protein 6<span class="elsevierStyleHsp" style=""></span>g/dL; glucose 22<span class="elsevierStyleHsp" style=""></span>mg/dL; LDH 1.066<span class="elsevierStyleHsp" style=""></span>U/L, scarce polymorphonuclear cells without the presence of Gram staining bacteria. The patient was initially treated for pneumonia associated with a complicated pleural effusion and was intubated through the right hemithorax and started receiving <span class="elsevierStyleSmallCaps">IV</span> moxifloxacin 400<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h and <span class="elsevierStyleSmallCaps">IV</span> meropenem 1<span class="elsevierStyleHsp" style=""></span>g every 8<span class="elsevierStyleHsp" style=""></span>h; subsequently, said schedule was replaced by <span class="elsevierStyleSmallCaps">IV</span> vancomycin 500<span class="elsevierStyleHsp" style=""></span>mg every 6<span class="elsevierStyleHsp" style=""></span>h and <span class="elsevierStyleSmallCaps">IV</span> piperacillin 4<span class="elsevierStyleHsp" style=""></span>g/tazobactam 0.5<span class="elsevierStyleHsp" style=""></span>g every 6<span class="elsevierStyleHsp" style=""></span>h. However, during the following days no clinical or radiological improvement was observed, and pleural fluid drainage persisted despite said antimicrobial schedules. The results of the acid-fast bacilli smear, pleural fluid cultures, and blood cultures were negative. After a lengthy hospital stay, the patient showed systemic dermatosis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>a), and in a skin biopsy, a lymphocytic vasculitis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>c) was documented. This scenario was initially attributed to an antimicrobial adverse effect. Viral hepatitis B and C, HIV, VDRL, pANCA and cANCA profiles were all negative. It was only after a detailed physical exam that some ulcers were found in the penis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>b); however, the result of the pathergy test was not conclusive. The case was diagnosed as an incomplete form of Behçet's disease versus ANCA-negative Wegener's granulomatosis; for this reason, the patient was treated with <span class="elsevierStyleSmallCaps">IV</span> methylprednisolone 125<span class="elsevierStyleHsp" style=""></span>mg every 6<span class="elsevierStyleHsp" style=""></span>h, showing a rapid improvement in his general and breathing conditions, which enabled the successful removal of thoracic intubation and hospital discharge soon after having started treatment. Unluckily, the patient died a few weeks later due to a clinical picture of diffuse alveolar haemorrhage.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">We presented the case of a patient with a complex, active, systemic vasculitic syndrome, with no kidney compromise, with inconclusive lab results, and associated with a pleural effusion not attributed to sequelae, comorbidities, or complications of any medical treatment, which eventually resulted in a fatal outbreak or relapse a few weeks following discharge. From the clinical point of view, it poses a diagnostic challenge given its low prevalence and the unspecified nature of the symptoms, which may overlap with those produced by other diseases, including the different types of SV. In spite of the fact that the presence of pleural effusion may not represent a major criterion of the SV clinical spectrum, it may indeed delay diagnosis and treatment on many occasions, causing disastrous results, mainly in sites where significant similarities with diseases featuring a higher prevalence, such as tuberculosis,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> exist. Pleural effusion has hardly ever been reported<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> as a form of presentation of SV; however, the incidence of this complication on Wegener's disease has been described to be in the range of 5%–55% and on Behçet's disease up to 20%.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2,3</span></a> Nevertheless, as pleural effusion could be attributed to vasculitis itself, other clinical conditions that are often associated with SV, such as thrombosis, infections, and heart or kidney failure, should be excluded first. Up to date, there exists no distinctive cytochemical profile of pleural effusion produced by SV. The presence of exudate acidosis with a low concentration of glucose has suggested the diagnosis of another type of SV and, likewise, the closed pleural biopsy has occasionally contributed to showing pleural vasculitis.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4,5</span></a> Similarly, and as mentioned hereinbefore, it is imperative to consider other clinical entities showing pleural fluid acidosis and low glucose (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) since vasculitic pleural effusion treatment and prognosis correspond to those of the underlying disease. Therefore, we suggest that the physician pay attention to the presence of those clinical findings suggestive of SV in each and every patient showing pleural fluid acidosis of unknown origin.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Flores-Franco RA, Ramos-Martínez E. Derrame pleural vasculítico. Reumatol Clin. 2015;11:186–187.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 468 "Ancho" => 1300 "Tamanyo" => 74221 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a) Chest X-ray showing a right-sided pleural effusion. (b) The computed tomography showed left lung pulmonary opacities besides the pleural effusion.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 393 "Ancho" => 1600 "Tamanyo" => 133897 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(a) Small flat and reddish spots in lower extremities produced by skin vasculitis. (b) Painful penis ulceration. (c) Microphotography where dense lymphocytic inflammation is observed around the wall of a small vessel in a sample collected from the dermis (H&E, 400×).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1740 "Ancho" => 2655 "Tamanyo" => 367892 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Study proposal of the patient with pleural fluid acidosis and low glucose concentration. Diagnostic priorities will always be the entities mentioned on the left. Vasculitic pleural effusion will always be a diagnosis of exclusion of the said diseases. ANA, antinuclear antibodies; ADA, adenosine deaminase.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Wegener granulomatosis revealed by pleural effusion" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.C. Toffart" 1 => "F. Arbib" 2 => "S. Lantuejoul" 3 => "J.F. Roux" 4 => "V. Bland" 5 => "G. 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Gökmen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Roentgenol" "fecha" => "1995" "volumen" => "164" "paginaInicial" => "51" "paginaFinal" => "56" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001100000003/v2_201505050301/S2173574315000416/v2_201505050301/en/main.assets" "Apartado" => array:4 [ "identificador" => "8400" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001100000003/v2_201505050301/S2173574315000416/v2_201505050301/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574315000416?idApp=UINPBA00004M" ]
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| 2024 March | 153 | 33 | 186 |
| 2024 February | 104 | 34 | 138 |
| 2024 January | 98 | 28 | 126 |
| 2023 December | 98 | 30 | 128 |
| 2023 November | 121 | 40 | 161 |
| 2023 October | 115 | 44 | 159 |
| 2023 September | 118 | 39 | 157 |
| 2023 August | 120 | 21 | 141 |
| 2023 July | 107 | 39 | 146 |
| 2023 June | 111 | 27 | 138 |
| 2023 May | 139 | 33 | 172 |
| 2023 April | 77 | 13 | 90 |
| 2023 March | 125 | 33 | 158 |
| 2023 February | 111 | 42 | 153 |
| 2023 January | 102 | 40 | 142 |
| 2022 December | 87 | 47 | 134 |
| 2022 November | 100 | 37 | 137 |
| 2022 October | 93 | 53 | 146 |
| 2022 September | 98 | 47 | 145 |
| 2022 August | 65 | 38 | 103 |
| 2022 July | 65 | 39 | 104 |
| 2022 June | 86 | 53 | 139 |
| 2022 May | 99 | 42 | 141 |
| 2022 April | 144 | 52 | 196 |
| 2022 March | 158 | 56 | 214 |
| 2022 February | 186 | 33 | 219 |
| 2022 January | 117 | 45 | 162 |
| 2021 December | 92 | 42 | 134 |
| 2021 November | 89 | 45 | 134 |
| 2021 October | 136 | 59 | 195 |
| 2021 September | 138 | 60 | 198 |
| 2021 August | 112 | 46 | 158 |
| 2021 July | 101 | 56 | 157 |
| 2021 June | 134 | 46 | 180 |
| 2021 May | 123 | 48 | 171 |
| 2021 April | 214 | 87 | 301 |
| 2021 March | 123 | 29 | 152 |
| 2021 February | 107 | 33 | 140 |
| 2021 January | 89 | 24 | 113 |
| 2020 December | 71 | 20 | 91 |
| 2020 November | 91 | 23 | 114 |
| 2020 October | 108 | 20 | 128 |
| 2020 September | 209 | 29 | 238 |
| 2020 August | 112 | 27 | 139 |
| 2020 July | 119 | 25 | 144 |
| 2020 June | 62 | 28 | 90 |
| 2020 May | 54 | 16 | 70 |
| 2020 April | 38 | 22 | 60 |
| 2020 March | 18 | 7 | 25 |
| 2018 May | 9 | 0 | 9 |
| 2018 April | 56 | 6 | 62 |
| 2018 March | 73 | 4 | 77 |
| 2018 February | 54 | 2 | 56 |
| 2018 January | 55 | 4 | 59 |
| 2017 December | 55 | 4 | 59 |
| 2017 November | 51 | 10 | 61 |
| 2017 October | 58 | 4 | 62 |
| 2017 September | 40 | 4 | 44 |
| 2017 August | 49 | 16 | 65 |
| 2017 July | 42 | 16 | 58 |
| 2017 June | 65 | 14 | 79 |
| 2017 May | 65 | 19 | 84 |
| 2017 April | 64 | 16 | 80 |
| 2017 March | 47 | 13 | 60 |
| 2017 February | 108 | 19 | 127 |
| 2017 January | 55 | 8 | 63 |
| 2016 December | 82 | 22 | 104 |
| 2016 November | 77 | 10 | 87 |
| 2016 October | 131 | 15 | 146 |
| 2016 September | 162 | 3 | 165 |
| 2016 August | 104 | 4 | 108 |
| 2016 July | 51 | 10 | 61 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 1 | 0 | 1 |
| 2015 November | 2 | 11 | 13 |
| 2015 October | 1 | 15 | 16 |
| 2015 September | 3 | 0 | 3 |
| 2015 August | 1 | 19 | 20 |
| 2015 July | 16 | 8 | 24 |
| 2015 June | 57 | 36 | 93 |
| 2015 May | 72 | 22 | 94 |
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