Bubbles in the Box: Recurrent Pneumothorax From Bronchopleural Fistula in Rheumatoid Arthritis

Abstract

When considering rheumatoid arthritis (RA)-associated pulmonary diseases, interstitial lung disease and pleural disease are the most common RA-associated pulmonary manifestations while spontaneous pneumothorax and bronchopleural fistula (BPF) are among the extremely rare ones. To the best of our knowledge, all the previous reports of RA-associated BPFs were attributed to peripherally located pulmonary nodules that necrotized, burst into the pleural cavity, and eventually lead to the fistula formation. However, we hereby present the first case of BPF in an RA patient that formed in the absence of any underlying rheumatic pulmonary nodules. Additionally, our patient was on chronic methotrexate therapy, and there are no data in the literature that suggest methotrexate-induced parenchymal lung disease can predispose to BPF formation. Our report is the first to introduce a probe to further investigate this association.

Takayasu arteritis presenting with spontaneous pneumothorax

“…14 There is no data in the literature that suggest that methotrexate-induced parenchymal lung disease can predispose to the development of pneumothorax and bronchopleural fistula. 15 Gotsman et al 16 described a case of pneumothorax secondary to the cavitation of a rheumatoid nodule during methotrexate treatment. It was speculated that methotrexate might have aggravated the previous pulmonary involvement.…”