Bilateral hydropneumothoraces in a patient with pulmonary rheumatoid nodules during treatment with methotrexate

Extra-articular manifestations in rheumatoid arthritis (RA), in particular rheumatoid nodules, are common. The most common pulmonary manifestations are pleural abnormalities and interstitial lung disease.1 Nodules observed on a chest x ray examination are a well known diagnostic dilemma in patients with RA, given the differential diagnosis of malignancy and rheumatoid nodules. Spontaneous pneumothorax secondary to pulmonary rheumatoid nodules is an uncommon complication of RA.2,3 A 73 year old female patient was admitted for cough, fever, and dyspnoea. She had had seropositive RA for 15 years, and had a history of chronic bronchitis, heart failure, diabetes mellitus, and hypothyroidism. She had been treated for 1 year with prednisone 7.5 mg/day and methotrexate (MTX), for active arthritis. The MTX dose was raised to 12.5 mg/week a month before presentation. …