Chest
Volume 136, Issue 4, October 2009, Pages 1144-1147
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Selected Reports
Pseudochylothorax Without Pleural Thickening: Time to Reconsider Pathogenesis?

https://doi.org/10.1378/chest.09-0445Get rights and content

Pseudochylothorax (cholesterol pleurisy or chyliform effusion) is a cholesterol-rich pleural effusion that is commonly associated with chronic inflammatory disorders such as tuberculosis or rheumatoid arthritis. Until now, there were only 15 published cases of arthritis-associated pseudochylothorax in the English language literature. Previous literature has suggested that pleural fluid cholesterol enrichment occurs in the context of grossly thickened (fibrotic) pleura over a prolonged period, usually > 5 years. We present six well-characterized cases of arthritis-associated pseudochylothorax, each notable due to their minimal pleural thickening. The median duration of symptoms (or arthritis, in the case of asymptomatic effusions) was 15 months. Such findings cast significant doubt on the conventional concepts of the pathogenesis of rheumatoid-associated pseudochylothorax. Clinicians should consider pseudochylothorax even in short-duration nonfibrotic pleural effusions.

Section snippets

Patient A

A 67-year-old man was found to have an asymptomatic unilateral effusion seen on chest radiography. He had a 2-year history of rheumatoid arthritis that was treated with methotrexate, nonsteroidal antiinflammatory therapy, and tramadol. There was no pleural thickening on a CT scan with pleural phase contrast enhancement (Fig 1). Thoracoscopy confirmed a lack of gross thickening on direct visual inspection. A postthoracoscopy chest radiograph (Fig 2) demonstrated the lack of thickening. The

Discussion

This case series described six patients with arthritis-related pseudochylothorax of modestly rapid onset and in the absence of a typical thick pleural peel; five patients had seropositive rheumatoid disease, and one patient had seronegative arthritis. Pseudochylothorax is an uncommon and underrecognized condition. Although rheumatoid arthritis is stated to be the second most common underlying cause, to our knowledge, there are only 15 published cases of such association in the English language

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: The authors are grateful to Mrs. Nicky Richards for secretarial assistance in case file retrieval.

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Funding/Support: This research was supported by the NIHR Oxford Biomedical Research Centre, UK (Dr. Davies), Medical Research Council, UK, and National Health & Medical Research Council, Australia (Dr. Lee), Department of Health & Higher Education Funding Council for England (HEFCE), Senior Clinical Lecturer awards (Drs. Maskell and Lee), and NIHR Academic Clinic Fellow programme, UK (Dr. Wrightson).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

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