Rheumatic pneumonia (RP) is a well described and poorly understood complication of acute rheumatic fever (ARF).
An 18 year old man was admitted to our hospital because of a 10 day history of fever, malaise, and dry cough.
Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella species, cytomegalovirus, and Epstein-Barr virus were negative. Computed tomography scan of the chest showing consolidation in the left lower lobe with associated pleural effusion.
On the 14th day after admission to hospital the patient developed arthritis at the left knee and the right wrist.
The antibiotic treatment was discontinued and acetylsalicylic acid (1.5 g four times a day) was started.
The radiological lesion improved progressively, and antistreptolysin O and C reactive protein normalised. Free sample This recent issue is free to all users to allow everyone the opportunity to see the full scope and typical content of ARD. Don't forget to sign up for content alerts so you keep up to date with all the articles as they are published. A 34 year-old woman with a history of heavy alcohol use presents to the emergency room complaining of increasing shortness of breath and right-sided chest pain. She initially undergoes thoracentesis for symptom relief but studies are not performed on the fluid.


Although the presence of eosinophils in blood is extremely helpful from a diagnostic standpoint, they have much less diagnostic utility when they are present in pleural fluid. In a patient with a history of multiple episodes of pancreatitis related to alcohol use you should consider ordering an amylase level in the pleural fluid. The arrow in the scan points to a pancreatic pseudocyst from her prior episodes of pancreatitis. How can you distinguish between pancreatic and other causes of amylase-rich pleural effusions? In amylase rich pleural effusions due to pancreatic causes, the amylase is largely the pancreatic isoenzyme while in cases of malignancy or esophageal rupture, it is usually the salivary isoenzyme that is present.
Her effusion is due to the fact that fluid is tracking from the pancreatic pseudocyst to the pleural space. Her past medical history is remarkable for several prior episodes of pancreatitis, likely secondary to her chronic alcohol use. A repeat thoracentesis is then performed and 2 liters of serosanguinous fluid are removed. Other potential tests you can order on exudative effusions of unclear etiology include a rheumatoid factor to rule out chronic rheumatoid pleurisy, ANA to rule out lupus pleuritis, adenosine deaminase to rule out tuberculosis and perhaps a pH and glucose as very low levels on those two tests might narrow your differential a bit (this is discussed in a later case). The initial management strategy is to promote decompression of the pseudocyst by allowing it to drain in another direction.
This prompts the physicians to order a pleural fluid amylase, which comes back at 4855 (normal < 20).


The leading items on the differential diagnosis for an elevated pleural fluid amylase is short and includes acute pancreatitis, chronic pancreatitis (pleural fluid tracks to the pleural space from a pancreatic pseudocyst), malignancy and esophageal rupture. To facilitate this, patients typically undergo ERCP with stenting of the pancreatic duct, which allows fluid to drain from the pseudocyst to the intestinal tract rather than to the pleural space. Less common causes include ovarian adenocarcinoma, ruptured ectopic pregnancy and chronic lymphocytic leukemia. In this patient’s case the presence of a pancreatic pseudocyst makes it highly likely that she has a pancreatico-pleural fistula with fluid tracking from the pseudocyst to the pleural space.
The old saw used to be that high eosinophil counts in the pleural fluid were highly suggestive of malignancy but subsequent case series showed that malignancy accounted for only 11-30% of effusions with > 10% eosinophils. The list of other diagnoses that can cause eosinophil rich pleural effusions is very large but the most common causes include parapneumonic effusions, tuberculosis, pulmonary embolism, lymphoma, eosinophilic pneumonia, pancreatic pseudocysts and a host of others.
Large numbers of eosinophils in the pleural fluid are not typical for the type of effusion this patient was found to have.



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Comments

  1. 01.12.2014 at 15:19:53


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    Author: I_S_I
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