Joudeh, N.

Abstract Introduction Rheumatoid arthritis (RA) is a systemic autoimmune rheumatic disease (SARD) primarily associated with articular involvement, but is often associated with lung involvement, sometimes preceding articular symptoms. Common pulmonary manifestations include interstitial lung disease (ILD), airway, and serosal involvement. RA-related pleural disease can mimic empyema due to the pleural fluid's green, pus-like appearance, exudative nature, low pH, markedly low glucose, and elevated lactate dehydrogenase (LDH) levels. Empyema sometimes yields negative cultures which can accentuate the diagnostic challenge in such cases. This report presents a patient with RA-related pleural lung disease who was referred to our hospital with trapped lung presumed to be secondary to empyema in the setting of pleural-based pulmonary abscess. Case Report A 66-year-old female with a 22-year history of RA presented with recurrent right-sided pleural effusions and progressive dyspnea over three years. Her initial presentation in 2022 involved a large right-sided pleural effusion, suspected to result from a ruptured pleural-based pulmonary abscess that led to empyema and subsequently a trapped lung. Pleural fluid analysis showed elevated LDH (1364 U/L), low glucose (45 mg/dL), high cholesterol (121 mg/dL), and low triglycerides (79 mg/dL). Due to refractory exudative effusion and a comprehensive negative infectious evaluation (bacterial, mycobacterial, and fungal cultures), RA-related pleural disease was suspected. The patient underwent video-assisted thoracoscopic surgery (VATS), which revealed pleural-based rheumatoid nodules and pleural thickening. (figure1) Lung and pleural biopsies confirmed RA-associated fibrinous pleuritis, RA-associated follicular bronchiolitis, and usual interstitial pneumonitis. Given the complexity of the infection, a thoracotomy with decortication and pleurectomy was planned and conducted in stages. Immunosuppressive regimen was switched from leflunomide to rituximab. Discussion This case underscores the diagnostic complexity in distinguishing RA-associated pleural effusion from empyema. Features such as pleural nodularity resembling a pulmonary abscess, unilateral exudative effusion, grossly purulent pleural fluid, low pH and glucose, and elevated LDH levels led to an initial misdiagnosis of empyema. Characteristic pleural fluid, along with persistent negative cultures and absence of sepsis pointed towards RA-related pleural disease. VATS and biopsy were instrumental in establishing the final diagnosis through characteristic histopathological findings of RA-associated pleural, parenchymal and airway involvement. Conclusion For RA patients with pleural effusion suggestive of empyema, especially in the context of negative cultures and no signs of sepsis, RA-related pleural disease should be a consideration. Early recognition and timely immunosuppressive therapy escalation can prevent complications such as trapped lungs and reduce the necessity for extensive surgical interventions. Figure1:

Abstract RATIONALE: Women are more likely to develop asthma after puberty, and their symptoms can fluctuate during the menstrual cycle, pregnancy, and menopause. Menopausal women with asthma face unique challenges, as hormonal fluctuations during this stage can impact respiratory health. About one-third of women undergo hysterectomy before age 60, with most procedures occurring before natural menopause. While half of these surgeries preserve the ovaries, the other half include oophorectomy, creating distinct hormonal environments. Despite the traditional view of the uterus as hormonally inactive, there remains a critical gap in our understanding of the potential impact of hysterectomy on respiratory health.METHODS: We used data from nine two-year cycles (1999-2000 to 2015-2016) from NHANES to determine the association between hysterectomy and asthma phenotypes. Severe asthma was defined based on GINA treatment classes 4&5. Analytic sample weights were used according to published NHANES guidelines to create national estimates. Asthma status (lifetime, active, severe) was obtained for women without (weighted n=90,348,593) or with a history of hysterectomy (weighted n=22,310,898). Weighted logistic regression analyses were used to determine the impact of hysterectomy on asthma prevalence, severity, exacerbations, and asthma-related emergency room (ER) visits adjusting for age, race, body mass index (BMI), smoking history, blood eosinophil count, a history of unilateral or bilateral oophorectomy, female hormone therapy, and oral contraceptive use. Analyses were performed using the SURVEY package in R.RESULTS: Clinical characteristics of women with and without a history of hysterectomy are listed in Table 1. Overall, hysterectomy was associated with higher asthma prevalence (18.1 vs. 15.1%) and severity (5.1 vs. 2.9%). For all women, hysterectomy was associated with a higher risk for lifetime asthma (adjusted OR, 1.262; 95% CI, 1.1079-1.477) but not for active asthma (adjusted OR, 1.146; 95% CI, 0.93-1.412) or severe asthma (adjusted OR, 0.996; 95% CI, 0.748-1.325). Interestingly, oophorectomy was associated with a higher risk for lifetime asthma (adjusted OR, 1.228; 95% CI, 1.102-1.368 for unilateral; adjusted OR, 1.232; 95% CI, 1.232-1.513 for bilateral) and active asthma (adjusted OR, 1.417; 95% CI, 1.232-1.629 for unilateral; adjusted OR, 1.507; 95% CI, 1.143-1.986 for bilateral). Among women with active asthma, hysterectomy was associated with severe exacerbations requiring ER visits (adjusted OR, 1.845; 95% CI, 1.157-2.941) but not with non-severe exacerbations (adjusted OR, 1.176; 95% CI, 0.811-1.705).CONCLUSIONS: This study highlights the influence of hysterectomy on asthma risk and severity and emphasizes the role of female hormones in asthma pathogenesis.