Therapeutic options for refractory massive pleural effusion in systemic lupus erythematosus: a case study and review of the literature

Abstract

Objectives: Massive refractory pleural effusions are uncommon in patients with systemic lupus erythematosus. Describing such a patient, the literature was reviewed to report the various therapeutic options in such cases.

Methods: MEDLINE search using the terms "lupus" and "pleural effusion," inclusion of cases with refractory massive effusions with emphasis on treatment.

Results: Only 10 such cases (including the patient described here) were reported in the English literature over the past 25 years. Those 10 patients suffered symptoms related to pleural effusion for a long period of time until resolution, ranging between 2 months to 2.5 years (median 6 months). During that period of time they underwent multiple fluid aspirations. Seven different types of therapy were reported in these case descriptions. They can be divided into 2 major groups: systemic therapy (immunosuppressive therapy, plasmapheresis, and intravenous immunoglobulin) and local therapy (intrapleural steroid injections, pleurodesis with talc or tetracycline, and pleurectomy). Pleurodesis with talc seemed to be the most effective treatment modality.

Conclusions: Due to the small number of reported patients, the best type of intervention is uncertain. When refractory pleural effusion is part of lupus exacerbation, the treatment of choice would be systemic, such as immunosuppressive therapy with high-dose steroids and cyclophosphamide. Intravenous immunoglobulin may also be considered. Local measures such as talc pleurodesis should be employed if systemic measures fail, or when pleural effusion is the only manifestation of lupus.