Background: Pleurisy is observed in almost 30% and effusions can be recurrent, occasionally leading to fibrothorax in chronic seropositive rheumatoid arthritis[Chest 1991; 100:235-238]. Pulmonary nodules occur in up to 5%, 50% cavitating to cause pneumothorax, haemoptysis or bronchopleural fistula.

Recurrent pneumothoraces and effusions are difficult to manage by surgical decortication [J Thor Cardiovasc Surg 1975; 68: 347-354].
Case Series: We report four cases of chronic seropositive rheumatoid arthritis on longterm immunomodulator therapy, presenting with pleural effusions which were prone to recurrence & complicated by development of pneumothorax. The common theme was all had chest drains inserted initially, then surgical pleurodesis, re-presented with recurrent pleural effusions draining purulent material after failed pleurodesis and had indwelling pleural catheters inserted. One isolated Aspergillus species and died of multiorgan failure; the rest were left with indwelling chest drains.
Discussion: Our case series highlights the paucity of evidence in management of complicated rheumatoid pleural disease and calls for registries of interventions for such patients. It is important to initiate early conservative approach in management of rheumatoid pleural effusions as surgical management is problematic due to trapped lung and pleural rind. Opportunistic infections in the context of an ever expanding use of immunosuppressive treatments have to be borne in mind.