B43-47 No Rheum for Air: Recurrent Pneumothoraces in Rheumatoid Arthritis

Abstract Introduction Rheumatoid arthritis (RA) is a systemic autoimmune disease that can involve the lungs in up to 60% of patients. Pulmonary manifestations range from interstitial lung disease and pleural effusions to less common necrobiotic or cavitating pulmonary nodules. While often asymptomatic, these nodules may cavitate and, rarely, rupture resulting in secondary spontaneous pneumothorax. Management is particularly challenging in patients with preexisting pulmonary comorbidities, such as chronic obstructive pulmonary disease (COPD), or when complicated by infection. We present a case illustrating the severe pulmonary sequelae of RA, including recurrent bilateral pneumothoraces, empyema, and fatal respiratory failure. Case Description A 51-year-old female with seropositive RA, COPD on long-term oxygen therapy, type 2 diabetes mellitus, morbid obesity, obstructive sleep apnea, and bipolar disorder presented with acute dyspnea and increased oxygen requirements. Her RA had been complicated by recurrent pleural effusions and cavitating pulmonary nodules. She had previously failed methotrexate, hydroxychloroquinone, leflunomide therapy and was recently restarted on adalimumab. CT imaging of the lung demonstrated bilateral pneumothoraces (left right), cavitary lung lesions, and bilateral pleural effusions. Thoracentesis revealed exudative pleural fluid consistent with RA-related effusion. She underwent bilateral chest tube placement and video-assisted thoracoscopic surgery (VATS) with pleurodesis for persistent pneumothorax. During hospitalization, she developed acute hypercapnic respiratory failure requiring intubation. Following transient extubation, she required re-intubation due to respiratory collapse. Her ICU course was complicated by sepsis, with pleural cultures positive for Pseudomonas aeruginosa and Finegoldia magna, consistent with empyema and pneumonia. She required broad-spectrum antibiotics and vasopressor support. Given her persistent air leak, poor respiratory reserve, obesity, and limited functional capacity, lung transplantation was not a viable option. After discussion of the limited therapeutic choices, the patient opted for comfort-centered care and passed away peacefully following extubation. Discussion Pulmonary complications of RA remain a significant cause of morbidity and mortality, particularly in refractory disease. Cavitating rheumatoid nodules are uncommon but can rupture, causing recurrent pneumothoraces and secondary infections. This case highlights the aggressive pulmonary course of RA despite biologic therapy and the challenges posed by comorbid COPD, obesity, and immunosuppression. Pleurodesis may help, but outcomes depend on response to anti-rheumatoid therapy and control of underlying inflammation. Recognition of severe RA phenotype requires early multidisciplinary management, careful risk-benefit assessment of immunosuppressive therapy, and timely discussions about goals of care. In advanced cases with poor pulmonary reserve, palliative integration is essential to optimize quality of life and patient-centered outcomes. This abstract is funded by: None