A woman with rheumatoidarthritis and a pleural effusion

The patient, a 64 year old woman, had a history of Rheumatoid Arthritis (RA) with an onset 3 years prior, diagnosed and followed at another communities’ rheumatology department, and had been treated with adalimumab and leflunomide since approximately 3 months prior, without a clinical report from her referral center. She had no prior history of cardio-respiratory disease. She came to the emergency department complaining of progressive dyspnea that had lasted for 3 days, progressing to breathlessness induced by minimal effort. The physical examination revealed the presence of bilateral basal crepitant rales, as well as diffuse roncus and tachyarrythmia The electrocardiogram confirmed the presence of atrial fibrillation (AF). Blood analysis showed leucocytosis and an elevated alanine aminotransferase (ALT) 702 UI/l , aspartate aminotransferase (AST) 278 UI/l, C reactive protein (CRP) 42 mg/l, lactate dehydrogenase (LDH) 485 UI/l, blood gas presented respiratory acidosis and D dimer (DD) was 0,35 μg/ml (reference value < 0,16). The chest x-ray showed an increase in the radio-opacity of alveolar and interstitial tissue and, due to the possibility of a pulmonary thromboembolism, an angioCAT scan was requested, showing a bilateral pleural effusion with bilateral laminar atelectasia (Figures 1-3).