ISOLATED TRlCUSPlD BACTERIAL ENDOCARDITIS

pulmonary parenchymal involvement in the disease. Patterson and co-workers3 found diffuse lung involvement in nine of 702 rheumatoid patients and noted more common occurrence in men. Pleuritis with effusion, the most common pulmonary manifestation,' is often transient, asymptomatic and develops at any stage of rheumatoid disease. In many instances pleural biopsy reveals only chronic idammatory changes but occasionally rheumatoid pleural nodules are found. The effusion which often accompanies pleuritis characteristically contains little or no measurable glucose; presumably this is the result of impaired pleural transport of the substance.5 Elevation of lactic dehydrogenase and lipids, eosinophilia and positive latex fixation tests are also foundes Cell counts are rarely helpful although RA cells have been demonstrated in these effusion^.^ Effusion without underlying pleural or parenchymal disease is uncommon. Other patients may present'with diffuse pulmonary fibrosis. In these, nodules are rarely present on roentgen0graphy.2.3.~ Of interest is the frequently positive latex fixation test found in some anarthritic patients with pulmonary f ibro~is .~ The relation of rheumatoid arthritis to conglomerate pulmonary fibrosis remains elusive. In 1953 Caplanl0 described a syndrome of massive pulmonary fibrosis and rheumatoid arthritis in coal miners. The nodular involvement in this variety tended to be more discrete than the usual variety of pulmonary fibrosis, with frequent coalescence and cavitation of the nodules. In some of Caplan and associatesl1 patientr rheumatoid factor without arthritis was demonstrated. Rheumatoid lung nodules may occur in the absence of diffuse parenchymal changes.4 Although infrequently seen in the absence of pneumoconiosis, these nodules favor corticopleural surfaces and posterior lung segments and frequently cavitate, as do the lesions described by Caplan. Histologically, these necrobiotic nodules contain a central zone of fibrinoid degeneration or necrosis, an immediate zone of proliferating cellular elements and a peripheral zone of inflammation (Fig 3). Solitary rheumatoid nodules are rarely seen in the lung. In 35 patients with rheumatoid lung lesions reported by Martel and colleagues4 only one solitary nodule was found. Cavitation of these lesions has been recorded.lZ Solitary lesions in the upper lung fields were confirmed in patients described by Mattingly,13 Christie," and Flatley.ls Although the nature of this solitary nodule was suspected clinically from the time of its discovery, only open biopsy finally cou!d prove the diagnosis. Not uncommonly the clinical syndromes of myopathy or arthropathy secondary to bronchogenic carcinoma might well simulate rheumatoid arthritis. Delineation of such lesions thus becomes increasingly important. 3 Patterson CD, H a ~ l l e WE, Pierce JA: Rheumatoid lung disease. Ann Intern Med 82:685, 1965 4 Martel W, Abell MR, Mikkelsen WM, et al: Pulmonary and pleural lesions in rheumatoid disease. Radiology 90:641, 1988 5 Carr DT, McCucken WF: Pleural fluid glucose: Serial observations of its concentration following oral administration of glucose in patients with rheumatoid pleural effusions and malignant effusions (abstract). Am Rev Resp Dis 97: 320, 1968 6 Campbell GD, Fenington E: Rheumatoid pleuritis with effusion. Dis Chest 53:521, 1988 7 Carmichael DS, Golding DN: Rheumatoid pleural effusion with "R A cells" in the pleural fluid. Br Med J 2:814, 1967 8 Cruickshank B: Interstitial pneumonia and its consequences in rheumatoid disease. Br J Dis Chest 55:228, 1959 9 Tomasi TB Jr, Fudenberg HH, Finby N: Possible relationship of rheumatoid factor and pulmonary disease. Am J Med 33:243, 1962 10 Caplan A: Certain unusual radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis. Thorax 8:29, 1953 11 Caplan A, Payne RB, Withey JL: Broader concept of Caplan's syndrome related to rheumatoid factors. Thorax 17:205, 1962 12 Yates DAH: Cavitation of a rheumatoid lung nodule. Ann Phys Med 7: 105, 1963 13 Mattingly S: The lungs and rheumatoid arthritis. Ann Phys Med 7: 185, 1964 14 Christie GS: Pulmonary lesions in rheumatoid arthritis. Australian Ann Med 3:49, 1954 15 Flatley FJ: Rheumatoid pulmonary disease. New Eng J Med 281: 1105, 1959