Rheumatoid arthritis for many years, but because of a "cold" into the emergency? ! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Fengbang final decision, waiting for you to decide! 01 arthritis for many years, "cold" after entering the emergency! The patient, a 52 year old female, had rheumatoid arthritis for many years. She took "traditional Chinese medicine pills" intermittently. Her hands were painful, deformed and stiff.this time, he was admitted to hospital because of "chest tightness and asthma for more than 3 months, aggravating for 7 days".the patient developed cough and expectoration after "cold" 3 months ago. The patient went to the local clinic for infusion treatment without obvious remission, and gradually developed chest tightness and asthma, edema of face and lower limbs, unable to lie down, obvious at night, less urine volume, aggravating chest tightness symptoms in recent 7 days, and went to our hospital for emergency treatment. Echocardiography: 1. Decreased left ventricular diastolic function; 2. Left ventricular wall thickening; 3. Mild aortic regurgitation; 4. Massive pericardial effusion.■ chest CT: 1. Bilateral pneumonia, bilateral pleural effusion with local collapse of both lower lungs; 2. Calcification in the right lower lobe of the lung; 3. Massive pericardial effusion; 4. Multiple lymph nodes of different sizes in mediastinum and bilateral axillary.the right chest drainage, oxygen inhalation and diuresis were given symptomatic treatment, chest tightness was slightly relieved, and the emergency department was admitted to our department.Figure 1: chest CT showed a large amount of pleural effusion and pericardial effusion ■ admission physical examination: body temperature: 37.6 ℃, pulse: 102 times / min, respiration: 21 times / min, blood pressure: 138 / 80mmHg.the skin color is normal.the right thoracic drainage tube was unobstructed, and the light yellow clear liquid was led out. The respiratory movement and respiratory frequency of both lungs were normal. The respiratory sounds of both upper and lower lungs were thick, and no respiratory sounds, dry and wet rales, wheezing and phlegm sounds were heard.the apical pulsation was weakened, the boundary of heart murmur was enlarged, the heart rate was 102 beats / min, the heart rhythm was homogeneous, the heart sound was low and distant, and no heart murmur was heard in each valve area.the abdomen is flat without varicose veins, intestinal type and peristaltic wave, tenderness and rebound pain, and no mass is touched.liver and spleen were not touched.bowel sounds were normal, no vascular murmur and friction sound were detected.■ auxiliary examination: routine blood test: hematocrit: 0.501 L / L ↑, hemoglobin 160g / L ↑, lymphocyte percentage 18.70% ↓, mean corpuscular hemoglobin 24.4pg ↓, mean corpuscular volume 76.3fl ↓, red blood cell count 6.57x1012 / L ↑, red blood cell distribution width 16.1% ↑; ESR: 3mm / h; urine routine examination: weak positive of urobilinogen (±); coagulation: D-dimer 1.30mg / L ↑ 10 μ g / ml @; blood biochemistry: albumin 36.9g / L ↓, total cholesterol 5.44mmol / L @, chlorine 93mmol / L ↓, creatinine 44 μ mol / L ↓, globulin 39.0g / L rise, glucose 7.1mmol / L rise, potassium 3.1mmol / L ↓, uric acid 762 μ mol / L ↑; humoral immunity: anti chain "O" (ASO) 138.0iu / ml rise, complement c30.650g / L ↑, C-reactive protein (CRP) 14.30mg / L / L @, C-reactive protein (CRP) 14.30mg / L / L @; humoral immunity: anti chain "O" (ASO) 138.0iu / ml @, complement c30.650g / L @, C c30.650g /;, immune Results: immunoglobulin G (IgG) 19.000g/l ↑, immunoglobulin kappa light chain 15.50g/l ↑, immunoglobulin λ light chain 9.79g/l ↑; thyroid function: free triiodothyronine (FT3) 3.65pmol/l ↓; autoantibody: anti cyclic citrullinated peptide antibody (RA / CP) determination (a-ccp) 55.9u / ml ↑, anti nuclear antibody (ANA) positive (+), anti nuclear antibody titer (ana-t) & gt; 1: Results: 1 000 ↑; tumor marker: carbohydrate antigen 125 (CA125) 530.30u/ml ↑; HLA-B27, T-SPOT, infectious diseases were not significantly abnormal; multiple sputum concentration tubercle bacillus test: no acid fast bacilli; routine pleural effusion: Li Fanta test positive (+); pleural fluid biochemistry: chlorine 92mmol / L ↓; pleural fluid test: adenosine deaminase 9u / L, antinuclear antibody titer (ana-t) 1:100 ↑; multiple pleural effusion Results: 1. Sinus tachycardia; 2. Atrial premature beat; 3. ST-T change; 4. P Ⅱ, III, AVF ≤ 0.3mV, heart rate: 1 113 times / min; bone mineral density: severe osteoporosis; whole abdominal CT: 1. Small cyst in right lobe of liver; 2. Pancreatic atrophy; 3. Small stone in left kidney; 4. Hyperosteogeny and destruction of bilateral hip joint with narrowing of joint space; 2. Thickening of ventricular septum; 3. Calcification of aortic valve with mild regurgitation; 4. Mild mitral regurgitation; 5. Massive pericardial effusion 。the elderly female patient has a history of rheumatoid arthritis for many years, and the treatment is irregular. At present, a large number of pericardial effusion and bilateral pleural effusion are the main clinical features.02 exclude tuberculosis and parasites? What's wrong with that? ■ further supplementary examination: "ascites (cell block)" section: mesothelial cell proliferation with mild chronic inflammation (Note: immunocytochemistry results showed: CK5 / 6 (2 +), D2-40 (3 +), HBME-1 (2 +), WT-1 (2 +), E-cad (-), TTF-1 (-), Ki-67 (10% +). The pathological diagnosis was combined with immunocytochemical results.human pulmonary parasite antibody: (-).differential diagnosis: Based on the history and examination results of the patient, exudate was considered as the nature of pleural effusion, no low sugar, no obvious symptoms of tuberculous blood, negative results of multiple tuberculous tests, no signs of tuberculosis in imaging, and insufficient evidence for diagnosis of tuberculosis; although tumor cells and atypical cells were found in the exfoliated cells of pleural effusion for many times, further pathological examination did not confirm pleural mesothelioma According to the fact that the antibody of pulmonary parasites was negative, the possibility of paragonimiasis was also ruled out.in the final diagnosis, rheumatoid arthritis associated polyserositis was considered.the patients were given thoracic puncture drainage, celecoxib, prednisone anti-inflammatory, methotrexate, leflunomide, cyclophosphamide immunosuppression and anti infection, diuresis and nutritional support treatment, the patient's chest tightness and asthma were relieved.chest CT scan after one month: 1. Scattered inflammation in the right lung; 2. Old lesions in the lower lobe of the right lung; 3. Atherosclerosis of aorta and coronary artery; pericardial effusion, obviously absorbed; 4. Multiple small lymph nodes in mediastinum and bilateral axillary, smaller than before.at present, the patient's condition is stable.Figure 2: chest and pericardial effusion significantly subsided after chest CT Reexamination. Summary of 03 cases: rheumatoid arthritis pleuropathy pleura is one of the common extraarticular involvement sites of rheumatoid arthritis. Although pleurisy is often found in autopsy, most of them may not have significant clinical symptoms.patients with clinical symptoms are mostly chest pain and fever. If there is a large amount of pleural effusion, dyspnea may occur.pleural effusion is mostly exudative, characterized by: sugar: 10-50mg / dl; protein: more than 4G / dl; cells (monocytes): 100-3500 / mm3; lactate dehydrogenase increased; CH50 decreased.rare pleural abnormalities include drug-induced pleurisy, empyema, bronchopleural fistula, hemopneumothorax and pyothorax.it should be noted that the nature of pleural effusion caused by infection may be similar to that of rheumatoid pleural effusion. Therefore, special attention should be paid to the cultivation of bacteria and Mycobacterium tuberculosis in order to exclude the possibility of infection, especially in patients who have long-term use of glucocorticoids.rheumatoid arthritis related heart disease in rheumatoid arthritis, about 30% of patients with rheumatoid arthritis can find pericardial effusion in echocardiography; autopsy shows that 50% of patients have pericarditis evidence; but clinically, less than 10% of patients have clinical symptoms of pericarditis.more rarely, constrictive pericarditis can lead to pericardial tamponade, which requires pericardiectomy.at the beginning of diagnosis, echocardiography showed a large number of pleural and pericardial effusion, but there was no pericardial tamponade symptoms, so pericardiocentesis was not performed.treatment for patients with pleural effusion and pericardial effusion that cannot subside, conventional treatment includes nonsteroidal anti-inflammatory drugs and glucocorticoids. If necessary, pleural cavity puncture, pleura fixation, pleural exfoliation and pericardial surgery can be used.for our patient, the manifestation was extremely rare large amount of pleural and pericardial effusion. Conventional glucocorticoid and pleural puncture and drainage did not achieve ideal results.cyclophosphamide treatment has a significant effect and may be used as one of the optional treatment methods.references 1. Balbir gurman a, yigla m, nahit am, et al. Rheumatoid plural effect. Semin arts Rheum. 2006; 35 (6): 368.2. Kelly ca. rheumatoid arthritis: typical rhamatoid lung disease. Baillieres Clin rheumatol. 1993; 7 (1): 13. Kelly rheumatology, 8th ed, Overview of rheumatoid arthritis associated lung lesions 5, Overview of systemic and extraarticular manifestations of rheumatoid arthritis: first issue: rheumatoid and nephrotic channel of medical circles You are welcome to submit to the editor's email: fs@yxj.org.cn Please note: [contribution] hospital + Department + name contribution is in the form of word document, others will not be considered. Wechat: ivy1571797296