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New Serositis in RA — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisNew Serositis in RASCE Rheumatology

A 42-year-old woman with seropositive rheumatoid arthritis has had well-controlled synovitis on methotrexate for 5 years. She develops new pleuritic chest pain, and imaging confirms a unilateral pleural effusion. Which is the most appropriate interpretation?

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Correct answer: D — Consider rheumatoid pleuritis, but investigate infection, malignancy, methotrexate toxicity and an overlapping connective-tissue disease.

Explanation lettering: C = shown as A · E = shown as B · B = shown as C · A = shown as E

D is correct. Rheumatoid arthritis can involve both the pleura and pericardium, so pleuritis does not exclude RA. However, a new unilateral pleural effusion—particularly when articular disease is controlled—must not be attributed to RA without investigation. Important alternatives include infection, including tuberculosis where epidemiologically relevant, malignancy, pulmonary embolism, an overlapping connective-tissue disease such as SLE, and treatment-related pulmonary toxicity. The UK methotrexate SmPC lists pleuritis, pleurisy and pleural effusion among reported pulmonary adverse effects and advises careful investigation of new pulmonary symptoms, including exclusion of infection. A and B incorrectly deny recognised rheumatoid pleural disease. C mistakes a possible association for a diagnosis of exclusion. E is too categorical: methotrexate toxicity is a differential diagnosis, not a finding specific to prolonged methotrexate exposure.

Reference: Yao X et al. Clinical perspective and practices on pleural effusions in chronic systemic inflammatory diseases. Breathe. 2020;16:200203. https://pubmed.ncbi.nlm.nih.gov/33447289/