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Unusual Presentations of Thoracic Tumors

Case 2. Malignant Mesothelioma Mimicking Rheumatoid Pleurisy

Tokyo Women’s Medical University, National Murayama Hospital, National Tokyo Hospital, and National Defense Medical College, Japan

In December 1999, a 59-year-old man, a smoker, was referred to the rheumatology service by his primary care physician. The patient exhibited right shoulder arthralgia with morning stiffness of the shoulder joint in September; analgesics brought only limited relief. In addition, he suffered from dyspnea, chest pain, and low-grade fevers, along with right-sided, massive pleural effusions. He had no digital clubbing. Rheumatoid pleurisy was suspected, as were metastatic lung cancer and pulmonary tuberculosis.

Results of blood studies were as follows: erythrocyte sedimentation rate, 59 mm/h; WBC count, 9,660/mL; hemoglobin level, 14.4 g/dL; platelet count, 46.0 x 10⁴/mL; serum protein level, 6.9 g/dL; lactate dehydrogenase level, 311 U/L; C-reactive protein level, 7.1 mg/dL; rheumatoid factor, positive; antinuclear antibody, positive (1:160); carcinoembryonic antigen level, 1.5 ng/mL; and hyaluronic acid level, 150 ng/mL (reference range, < 50 ng/mL). The pleural effusion showed the following: TP, 4.4 g/dL; lactate dehydrogenase level, 433 U/L; adenosine deaminase level, 20.4 IU/L; carcinoembryonic antigen level, 0.8 ng/mL; hyaluronic acid level, not measured; culture of tubercle bacillus and other bacteria, negative; and cytodiagnosis, class IIIa. After the effusion was drained, chest x-ray (Fig 1) and computed tomography scan (Fig 2) revealed many masses in the pleura covering the underlying normal lung. A diffuse mesothelioma or a metastatic pleural tumor was suspected, since rheumatoid pleurisy had been ruled out. Hematoxylin and eosin stain of the pleural biopsy specimen showed neoplastic cells and the presence of hyaluronic acid but no asbestos bodies (Fig 3). Mesothelioma markers, such as calretinin (Fig 4) and cytokeratin 5/6, were positively stained.¹ The patient was diagnosed as having malignant mesothelioma (epithelioid type). Approximately two thirds of mesotheliomas are associated with asbestos exposure,² and the occasional appearance of non–organ-specific autoantibodies, such as antinuclear antibodies and rheumatoid factor, has been associated with asbestos exposure.³ However, our patient had no definite history of such exposure.

View larger version (132K): [in this window] [in a new window]   Fig 1.

View larger version (118K): [in this window] [in a new window]   Fig 2.

View larger version (142K): [in this window] [in a new window]   Fig 3.

View larger version (140K): [in this window] [in a new window]   Fig 4.

Although mesotheliomas are much less frequent than metastatic pleural involvement and rheumatoid pleurisy, this case re-emphasizes that they can also be an etiologic factor of pleural effusions and that aggressive pleural biopsy is useful in confirming the diagnosis.

REFERENCES

1. Cury PM, Butcher DN, Fisher C, ET AL: Value of the mesothelium-associated antibodies thrombomodulin, cytokeratin 5/6, calretinin, and CD44H in distinguishing epithelioid pleural mesothelioma from adenocarcinoma metastatic to the pleura. Mod Pathol 13: 107-112, 2000[Medline]

2. Boylan AM: Mesothelioma: new concepts in diagnosis and management. Curr Opin Pulm Med 6: 157-163, 2000[Medline]

3. Turner-Warwick M, Parkes WR: Circulating rheumatoid and antinuclear factors in asbestos workers. Br Med J 3: 492-495, 1970

4. An analysis of 310 cases of pleural mesothelioma. Chung Hua Chieh Ho Ho Hu Hsi Tsa Chih 13:216-220, 254-255, 1990 (in Chinese, English abstract)

5. Mazel JA, Roolvink EG: Clinical judgment and decision making in medical practice: A patient with shoulder symptoms. Ned Tijdschr Geneeskd 141: 2234-2238, 1997 (in Dutch, English abstract)[Medline]

6. Soderblom T, Pettersson T, Nyberg P, et al: High pleural fluid hyaluronan concentrations in rheumatoid arthritis. Eur Respir J 13: 519-522, 1999[Abstract]

7. Laurent TC, Laurent UB, Fraser JR: Serum hyaluronan as a disease marker. Ann Med 28: 241-253, 1996[Medline]

8. Case records of the Massachusetts General Hospital: Weekly clinicopathological exercises—Case 27-1982. Pleural thickening in a man with rheumatoid arthritis and exposure to asbestos. N Engl J Med 307: 104-112, 1982[Medline]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Nanke, Y. Articles by Kamatani, N. Search for Related Content PubMed PubMed Citation Articles by Nanke, Y. Articles by Kamatani, N. Social Bookmarking                            What's this?