Intractable pneumothorax due to rupture of subpleural rheumatoid nodules: a case report

BACKGROUND: In rare cases, rheumatoid pleural nodules can rupture into the pleural cavity to cause pneumothorax or empyema. We report successful surgical treatment of a patient with an intractable secondary pneumothorax due to rupture of a subpleural rheumatoid nodule into the pleural cavity. CASE PRESENTATION: A 75-year-old man with a medical history of rheumatoid arthritis, acute coronary syndrome, and diabetes was admitted to our hospital because of left chest pain and dyspnea. A chest X-ray and chest computed tomography (CT) scan showed a left pneumothorax and several small subpleural nodules with cavitation. Repeated pleurodesis via a chest tube failed to improve the pneumothorax, so we decided to perform thoracoscopic surgery. Air leakage was detected in the left upper lobe where the subpleural nodule was visible on chest CT. Resection of the lesion successfully resulted in resolution of the air leakage. The final pathological diagnosis of the subpleural nodule was a pulmonary rheumatoid nodule. The patient has had no evidence of recurrence of pneumothorax after surgery. CONCLUSIONS: We obtained a final pathological diagnosis of a rheumatoid nodule that caused an intractable pneumothorax. Pneumothorax associated with rupture of rheumatoid nodules in the subpleural cavitary is difficult to treat with thoracoscopic surgery as a second-line treatment.