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Massive Spontaneous Hemopneumothorax Complicating Rheumatoid Lung Disease

2007; Elsevier BV; Volume: 83; Issue: 4 Linguagem: Inglês

10.1016/j.athoracsur.2006.09.052

1552-6259

Ahmet Başoğlu, Burçin Çelik, Tülin Durgun Yetim,

Pneumothorax, Barotrauma, Emphysema

Spontaneous hemopneumothorax is characterized by an accumulation of air and blood in the pleural space without any apparent cause. Massive spontaneous hemopneumothorax is a rare, life-threatening situation and requires an operation in the early stage. The most common manifestation of rheumatoid disease in the lung is pleural disease. This can occur with or without pleural effusion. Hemopneumothorax is very rarely seen as the pulmonary manifestations of rheumatoid disease. We present a case of massive spontaneous hemopneumothorax in a young patient with rheumatoid lung disease as an unusual complication. Spontaneous hemopneumothorax is characterized by an accumulation of air and blood in the pleural space without any apparent cause. Massive spontaneous hemopneumothorax is a rare, life-threatening situation and requires an operation in the early stage. The most common manifestation of rheumatoid disease in the lung is pleural disease. This can occur with or without pleural effusion. Hemopneumothorax is very rarely seen as the pulmonary manifestations of rheumatoid disease. We present a case of massive spontaneous hemopneumothorax in a young patient with rheumatoid lung disease as an unusual complication. Spontaneous hemopneumothorax, which was described initially in 1876 by Whittaker [1Whittaker J.T. Case of hemopneumothorax, relieved by aspiration.Clinic Cincinnati. 1876; 10: 793-798Google Scholar], involves the accumulation of air and blood within the pleural space in the absence of trauma or other obvious causes. It has been reported to occur in 2% to 7.3% of all cases of spontaneous pneumothorax [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. Massive spontaneous hemopneumothorax is an uncommon, life-threatening situation and requires surgical intervention.The collagen vascular disorders are a group of systemic disorders characterized by inflammation of vessels, connective tissues, and serosal surfaces. Each of these disorders may be associated with lung disease [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar]. Rheumatoid disease is a systemic disease of unknown origin that is characterized principally by chronic inflammation and destruction of joints. Pleural abnormalities are probably the must frequent manifestation of rheumatoid disease in the thorax [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 4Helmers R. Galvin J. Hunninghake G.W. Pulmonary manifestations associated with rheumatoid arthritis.Chest. 1991; 100: 235-238Crossref PubMed Scopus (67) Google Scholar]. We present a case of massive spontaneous hemopneumothorax in a young patient with rheumatoid lung disease as an unusual complication.A 35-year-old woman was admitted to the hospital with a history of progressive dyspnea. She had a 3-year history of rheumatoid arthritis with positive rheumatoid factor. She had been treated with prednisone in a dosage of 16 mg/day. She was a nonsmoker.On physical examination, she was pale and short of breath. Reduced breathing sounds and hyperresonant percussion on the left hemithorax suggested pneumothorax. Her initial heart rate was 114 beats/min, blood pressure was 100/60 mm Hg, respiratory rate was 34 breaths/min, and arterial oxygen saturation was 95% in room air. A chest roentgenogram taken at admission revealed a hydropneumothorax on the left hemithorax with mediastinal shift (Fig 1). A chest computed tomography scan revealed infiltration in the upper lobe parenchyma on the left hemithorax (Fig 2). Thoracentesis revealed bloody fluid.Fig 2A chest computed tomography scan reveals infiltration in the upper lobe parenchyma.View Large Image Figure ViewerDownload (PPT)Laboratory study results were white blood cell count, 12950/mm3; hemoglobin level, 9.8 g/dL; hematocrit, 28%; platelet count, 392.000/mm3; erythrocyte sedimentation rate, 60 mm at 1 hour; protein level, 5.3 g/dL; lactate dehydrogenase level, 537 U/L; and glucose level, 91 mg/dL. Pleural fluid counts were white blood cells, 18000/mm3; hemoglobin, 8.7 g/dL; hematocrit, 25%; protein, 3.2 g/dL; lactate dehydrogenase, 422 U/L; and glucose, 61 mg/dL.A thoracostomy tube was inserted, with an initial drainage of 1200 mL of fresh blood and air. The patient was closely monitored. During the next 2 hours, 600 mL of blood was drained. Episodes of hypotension developed despite aggressive fluid replacement and the patient underwent an emergent thoracotomy in the operating room.During the operation, 1000 mL of clotted blood was found inside the left pleural cavity. Active bleeding was identified from the lingular branch of the pulmonary artery, and there was a partial necrosis in the upper and lower lobe parenchyma. The lingular branch of the pulmonary artery was ligated, and the necrotizing lingular segment of the upper lobe was resected (wedge resection). Pathologic examination showed necrosis and acute inflammation in the lung parenchyma.Postoperatively, despite antibiotic therapy, empyema and sepsis developed. The patient’s condition deteriorated, and mechanical ventilation treatment was given for 15 days. During this time, we administered a steroid in high dosage (250 mg/day), and the patient recovered slowly. The chest tube was removed on postoperative day 30, and the patient discharged on postoperative day 45 in good condition. She is well 3 years postoperatively.CommentSpontaneous hemopneumothorax is defined as the accumulation of more than 400 mL of blood in the pleural cavity in association with spontaneous pneumothorax [5Ohmori K. Ohata M. Narata M. et al.28 cases of spontaneous hemopneumothorax.Nippon Kyobu Geka Gakkai Zasshi. 1988; 36: 1059-1064PubMed Google Scholar]. Spontaneous hemopneumothorax, although a well documented disorder, is encountered infrequently in clinical practice. The incidence rate of spontaneous hemopneumothorax ranges from 2% to 7.3% of spontaneous pneumothorax cases. The reported causes include torn pleural adhesions, rupture of the vascularized bullae, and aberrant vessels [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. Most hemothoraxes are due to bleeding from the low-pressure pulmonary parenchymal vessels. These vessels stop bleeding spontaneously when the hemothorax is evacuated and the pleural surfaces are reapposed [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 5Ohmori K. Ohata M. Narata M. et al.28 cases of spontaneous hemopneumothorax.Nippon Kyobu Geka Gakkai Zasshi. 1988; 36: 1059-1064PubMed Google Scholar, 6Hull S. Mathews J.A. Pulmonary necrobiotic nodules as a presenting feature of rheumatoid arthritis.Ann Rheum Dis. 1982; 41: 21-24Crossref PubMed Scopus (36) Google Scholar].Pleuropulmonary manifestations and complications of rheumatoid disease include pleural effusion, pneumothorax, pulmonary infections, pneumonitis and interstitial pulmonary fibrosis, pulmonary necrobiotic nodule, bronchogenic carcinoma, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, and amyloidosis [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 4Helmers R. Galvin J. Hunninghake G.W. Pulmonary manifestations associated with rheumatoid arthritis.Chest. 1991; 100: 235-238Crossref PubMed Scopus (67) Google Scholar]. Pleural involvement is probably the most common intrathoracic manifestation of rheumatoid disease, occurring in about 5% of patients. Patients with rheumatoid disease have an increased incidence of pleural effusion. Pleural effusions were more common in men than in women [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 7Light R.W. Pleural disease due to collagen vascular disease.in: Light R.W. Pleural diseases. 3rd ed. Williams & Wilkins, Philadelphia, PA1995: 208-218Google Scholar]. Pleural effusions are usually small and unilateral, but may be bilateral and large. The fluid is an exudate with high concentrations of protein and lactate dehydrogenase. The glucose concentration is usually low. Although the pleural effusions may resolve spontaneously, they may persist for long periods of time [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 4Helmers R. Galvin J. Hunninghake G.W. Pulmonary manifestations associated with rheumatoid arthritis.Chest. 1991; 100: 235-238Crossref PubMed Scopus (67) Google Scholar].Pulmonary necrobiotic nodules are a relatively rare manifestation of rheumatoid disease, occurring in less than 0.5% of patients. The nodules can cavitate and cause hemoptysis if they are close to a main bronchus, or they may cause pneumothorax if they are situated peripherally adjacent to the pleura [6Hull S. Mathews J.A. Pulmonary necrobiotic nodules as a presenting feature of rheumatoid arthritis.Ann Rheum Dis. 1982; 41: 21-24Crossref PubMed Scopus (36) Google Scholar]. We did not observe any pulmonary necrobiotic nodules perioperatively nor in the pathologic examination.Common presentations in cases of spontaneous hemopneumothorax are the sudden onset of chest pain or dyspnea, as the case of our patient illustrates [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 8Tatebe S. Kanazawa H. Yamazaki Y. Aoki E. Sakurai Y. Spontaneous hemopneumothorax.Ann Thorac Surg. 1996; 62: 1011-1015Abstract Full Text PDF PubMed Scopus (61) Google Scholar]. Initial management consists of resuscitation with adequate fluid replacement and drainage of the pleural space. In patients with massive hemopneumothorax, urgent surgical therapy is better than tube drainage alone. A thoracotomy provides the opportunity to stop the bleeding, evacuate coagulated blood from the pleural cavity, and secure effective drainage by drain placement under direct vision [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar].The various aspects of rheumatoid lung disease and its clinical significance have been reported, and we report here a rare case of massive spontaneous hemopneumothorax associated with rheumatoid lung disease. As in this patient, consideration should be given to rheumatoid disease being associated with unusual, life-threatening pulmonary complications. In these patients, urgent surgical therapy should be performed, and an operation in the early stage is likely to provide a good outcome. Spontaneous hemopneumothorax, which was described initially in 1876 by Whittaker [1Whittaker J.T. Case of hemopneumothorax, relieved by aspiration.Clinic Cincinnati. 1876; 10: 793-798Google Scholar], involves the accumulation of air and blood within the pleural space in the absence of trauma or other obvious causes. It has been reported to occur in 2% to 7.3% of all cases of spontaneous pneumothorax [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. Massive spontaneous hemopneumothorax is an uncommon, life-threatening situation and requires surgical intervention. The collagen vascular disorders are a group of systemic disorders characterized by inflammation of vessels, connective tissues, and serosal surfaces. Each of these disorders may be associated with lung disease [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar]. Rheumatoid disease is a systemic disease of unknown origin that is characterized principally by chronic inflammation and destruction of joints. Pleural abnormalities are probably the must frequent manifestation of rheumatoid disease in the thorax [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 4Helmers R. Galvin J. Hunninghake G.W. Pulmonary manifestations associated with rheumatoid arthritis.Chest. 1991; 100: 235-238Crossref PubMed Scopus (67) Google Scholar]. We present a case of massive spontaneous hemopneumothorax in a young patient with rheumatoid lung disease as an unusual complication. A 35-year-old woman was admitted to the hospital with a history of progressive dyspnea. She had a 3-year history of rheumatoid arthritis with positive rheumatoid factor. She had been treated with prednisone in a dosage of 16 mg/day. She was a nonsmoker. On physical examination, she was pale and short of breath. Reduced breathing sounds and hyperresonant percussion on the left hemithorax suggested pneumothorax. Her initial heart rate was 114 beats/min, blood pressure was 100/60 mm Hg, respiratory rate was 34 breaths/min, and arterial oxygen saturation was 95% in room air. A chest roentgenogram taken at admission revealed a hydropneumothorax on the left hemithorax with mediastinal shift (Fig 1). A chest computed tomography scan revealed infiltration in the upper lobe parenchyma on the left hemithorax (Fig 2). Thoracentesis revealed bloody fluid. Laboratory study results were white blood cell count, 12950/mm3; hemoglobin level, 9.8 g/dL; hematocrit, 28%; platelet count, 392.000/mm3; erythrocyte sedimentation rate, 60 mm at 1 hour; protein level, 5.3 g/dL; lactate dehydrogenase level, 537 U/L; and glucose level, 91 mg/dL. Pleural fluid counts were white blood cells, 18000/mm3; hemoglobin, 8.7 g/dL; hematocrit, 25%; protein, 3.2 g/dL; lactate dehydrogenase, 422 U/L; and glucose, 61 mg/dL. A thoracostomy tube was inserted, with an initial drainage of 1200 mL of fresh blood and air. The patient was closely monitored. During the next 2 hours, 600 mL of blood was drained. Episodes of hypotension developed despite aggressive fluid replacement and the patient underwent an emergent thoracotomy in the operating room. During the operation, 1000 mL of clotted blood was found inside the left pleural cavity. Active bleeding was identified from the lingular branch of the pulmonary artery, and there was a partial necrosis in the upper and lower lobe parenchyma. The lingular branch of the pulmonary artery was ligated, and the necrotizing lingular segment of the upper lobe was resected (wedge resection). Pathologic examination showed necrosis and acute inflammation in the lung parenchyma. Postoperatively, despite antibiotic therapy, empyema and sepsis developed. The patient’s condition deteriorated, and mechanical ventilation treatment was given for 15 days. During this time, we administered a steroid in high dosage (250 mg/day), and the patient recovered slowly. The chest tube was removed on postoperative day 30, and the patient discharged on postoperative day 45 in good condition. She is well 3 years postoperatively. CommentSpontaneous hemopneumothorax is defined as the accumulation of more than 400 mL of blood in the pleural cavity in association with spontaneous pneumothorax [5Ohmori K. Ohata M. Narata M. et al.28 cases of spontaneous hemopneumothorax.Nippon Kyobu Geka Gakkai Zasshi. 1988; 36: 1059-1064PubMed Google Scholar]. Spontaneous hemopneumothorax, although a well documented disorder, is encountered infrequently in clinical practice. The incidence rate of spontaneous hemopneumothorax ranges from 2% to 7.3% of spontaneous pneumothorax cases. The reported causes include torn pleural adhesions, rupture of the vascularized bullae, and aberrant vessels [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. Most hemothoraxes are due to bleeding from the low-pressure pulmonary parenchymal vessels. These vessels stop bleeding spontaneously when the hemothorax is evacuated and the pleural surfaces are reapposed [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 5Ohmori K. Ohata M. Narata M. et al.28 cases of spontaneous hemopneumothorax.Nippon Kyobu Geka Gakkai Zasshi. 1988; 36: 1059-1064PubMed Google Scholar, 6Hull S. Mathews J.A. Pulmonary necrobiotic nodules as a presenting feature of rheumatoid arthritis.Ann Rheum Dis. 1982; 41: 21-24Crossref PubMed Scopus (36) Google Scholar].Pleuropulmonary manifestations and complications of rheumatoid disease include pleural effusion, pneumothorax, pulmonary infections, pneumonitis and interstitial pulmonary fibrosis, pulmonary necrobiotic nodule, bronchogenic carcinoma, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, and amyloidosis [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 4Helmers R. Galvin J. Hunninghake G.W. Pulmonary manifestations associated with rheumatoid arthritis.Chest. 1991; 100: 235-238Crossref PubMed Scopus (67) Google Scholar]. Pleural involvement is probably the most common intrathoracic manifestation of rheumatoid disease, occurring in about 5% of patients. Patients with rheumatoid disease have an increased incidence of pleural effusion. Pleural effusions were more common in men than in women [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 7Light R.W. Pleural disease due to collagen vascular disease.in: Light R.W. Pleural diseases. 3rd ed. Williams & Wilkins, Philadelphia, PA1995: 208-218Google Scholar]. Pleural effusions are usually small and unilateral, but may be bilateral and large. The fluid is an exudate with high concentrations of protein and lactate dehydrogenase. The glucose concentration is usually low. Although the pleural effusions may resolve spontaneously, they may persist for long periods of time [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 4Helmers R. Galvin J. Hunninghake G.W. Pulmonary manifestations associated with rheumatoid arthritis.Chest. 1991; 100: 235-238Crossref PubMed Scopus (67) Google Scholar].Pulmonary necrobiotic nodules are a relatively rare manifestation of rheumatoid disease, occurring in less than 0.5% of patients. The nodules can cavitate and cause hemoptysis if they are close to a main bronchus, or they may cause pneumothorax if they are situated peripherally adjacent to the pleura [6Hull S. Mathews J.A. Pulmonary necrobiotic nodules as a presenting feature of rheumatoid arthritis.Ann Rheum Dis. 1982; 41: 21-24Crossref PubMed Scopus (36) Google Scholar]. We did not observe any pulmonary necrobiotic nodules perioperatively nor in the pathologic examination.Common presentations in cases of spontaneous hemopneumothorax are the sudden onset of chest pain or dyspnea, as the case of our patient illustrates [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 8Tatebe S. Kanazawa H. Yamazaki Y. Aoki E. Sakurai Y. Spontaneous hemopneumothorax.Ann Thorac Surg. 1996; 62: 1011-1015Abstract Full Text PDF PubMed Scopus (61) Google Scholar]. Initial management consists of resuscitation with adequate fluid replacement and drainage of the pleural space. In patients with massive hemopneumothorax, urgent surgical therapy is better than tube drainage alone. A thoracotomy provides the opportunity to stop the bleeding, evacuate coagulated blood from the pleural cavity, and secure effective drainage by drain placement under direct vision [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar].The various aspects of rheumatoid lung disease and its clinical significance have been reported, and we report here a rare case of massive spontaneous hemopneumothorax associated with rheumatoid lung disease. As in this patient, consideration should be given to rheumatoid disease being associated with unusual, life-threatening pulmonary complications. In these patients, urgent surgical therapy should be performed, and an operation in the early stage is likely to provide a good outcome. Spontaneous hemopneumothorax is defined as the accumulation of more than 400 mL of blood in the pleural cavity in association with spontaneous pneumothorax [5Ohmori K. Ohata M. Narata M. et al.28 cases of spontaneous hemopneumothorax.Nippon Kyobu Geka Gakkai Zasshi. 1988; 36: 1059-1064PubMed Google Scholar]. Spontaneous hemopneumothorax, although a well documented disorder, is encountered infrequently in clinical practice. The incidence rate of spontaneous hemopneumothorax ranges from 2% to 7.3% of spontaneous pneumothorax cases. The reported causes include torn pleural adhesions, rupture of the vascularized bullae, and aberrant vessels [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. Most hemothoraxes are due to bleeding from the low-pressure pulmonary parenchymal vessels. These vessels stop bleeding spontaneously when the hemothorax is evacuated and the pleural surfaces are reapposed [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 5Ohmori K. Ohata M. Narata M. et al.28 cases of spontaneous hemopneumothorax.Nippon Kyobu Geka Gakkai Zasshi. 1988; 36: 1059-1064PubMed Google Scholar, 6Hull S. Mathews J.A. Pulmonary necrobiotic nodules as a presenting feature of rheumatoid arthritis.Ann Rheum Dis. 1982; 41: 21-24Crossref PubMed Scopus (36) Google Scholar]. Pleuropulmonary manifestations and complications of rheumatoid disease include pleural effusion, pneumothorax, pulmonary infections, pneumonitis and interstitial pulmonary fibrosis, pulmonary necrobiotic nodule, bronchogenic carcinoma, arteritis with pulmonary hypertension, obliterative bronchiolitis, bronchiectasis, and amyloidosis [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 4Helmers R. Galvin J. Hunninghake G.W. Pulmonary manifestations associated with rheumatoid arthritis.Chest. 1991; 100: 235-238Crossref PubMed Scopus (67) Google Scholar]. Pleural involvement is probably the most common intrathoracic manifestation of rheumatoid disease, occurring in about 5% of patients. Patients with rheumatoid disease have an increased incidence of pleural effusion. Pleural effusions were more common in men than in women [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 7Light R.W. Pleural disease due to collagen vascular disease.in: Light R.W. Pleural diseases. 3rd ed. Williams & Wilkins, Philadelphia, PA1995: 208-218Google Scholar]. Pleural effusions are usually small and unilateral, but may be bilateral and large. The fluid is an exudate with high concentrations of protein and lactate dehydrogenase. The glucose concentration is usually low. Although the pleural effusions may resolve spontaneously, they may persist for long periods of time [3Joseph J. Sahn S.A. Connective tissue diseases and the pleura.Chest. 1993; 104: 262-270Crossref PubMed Scopus (66) Google Scholar, 4Helmers R. Galvin J. Hunninghake G.W. Pulmonary manifestations associated with rheumatoid arthritis.Chest. 1991; 100: 235-238Crossref PubMed Scopus (67) Google Scholar]. Pulmonary necrobiotic nodules are a relatively rare manifestation of rheumatoid disease, occurring in less than 0.5% of patients. The nodules can cavitate and cause hemoptysis if they are close to a main bronchus, or they may cause pneumothorax if they are situated peripherally adjacent to the pleura [6Hull S. Mathews J.A. Pulmonary necrobiotic nodules as a presenting feature of rheumatoid arthritis.Ann Rheum Dis. 1982; 41: 21-24Crossref PubMed Scopus (36) Google Scholar]. We did not observe any pulmonary necrobiotic nodules perioperatively nor in the pathologic examination. Common presentations in cases of spontaneous hemopneumothorax are the sudden onset of chest pain or dyspnea, as the case of our patient illustrates [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar, 8Tatebe S. Kanazawa H. Yamazaki Y. Aoki E. Sakurai Y. Spontaneous hemopneumothorax.Ann Thorac Surg. 1996; 62: 1011-1015Abstract Full Text PDF PubMed Scopus (61) Google Scholar]. Initial management consists of resuscitation with adequate fluid replacement and drainage of the pleural space. In patients with massive hemopneumothorax, urgent surgical therapy is better than tube drainage alone. A thoracotomy provides the opportunity to stop the bleeding, evacuate coagulated blood from the pleural cavity, and secure effective drainage by drain placement under direct vision [2Hsu N.Y. Shih C.S. Hsu C.P. Chen P.R. Spontaneous hemopneumothorax revisited: clinical approach and systemic review of the literature.Ann Thorac Surg. 2005; 80: 1859-1863Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar]. The various aspects of rheumatoid lung disease and its clinical significance have been reported, and we report here a rare case of massive spontaneous hemopneumothorax associated with rheumatoid lung disease. As in this patient, consideration should be given to rheumatoid disease being associated with unusual, life-threatening pulmonary complications. In these patients, urgent surgical therapy should be performed, and an operation in the early stage is likely to provide a good outcome.