A Rare Case of Malignant Mesothelioma Presenting with Systemic Lupus Erythematosus Seropositivity: A Case Report and Review of Literature

Our plain-English summary of A Rare Case of Malignant Mesothelioma Presenting with Systemic Lupus Erythematosus Seropositivity: A Case Report and Review of Literature, by A. Rakhra, A. Munir, R.S. Chilukuri, et al (Curēus, 2019).

The study

• Authors: A. Rakhra, A. Munir, R.S. Chilukuri, J. Nahas
• Journal: Curēus
• Published: 2019;11(2):e4092
• Type of article: Case report
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

While malignant mesothelioma may initially present in a variety of ways, it is uncommon to present with systemic lupus erythematosus (SLE) seropositivity and thus obscuring its diagnosis. Our case involves a 75-year-old Caucasian male with a past medical history of essential hypertension, remote prostate cancer status post prostatectomy, and lifetime nontobacco use presenting with progressive shortness of breath over one month. After a negative cardiac assessment, a postcardiac catheterization chest X-ray (CXR) revealed a right-sided moderate-to-large pleural effusion that, on further workup, was found to be exudative. Effusion studies were negative for malignancy and bacterial growth. Recurrent accumulation of fluid after a thoracentesis one week prior prompted an autoimmune work up. Positive markers included antinuclear antibodies, anti-double stranded DNA antibodies, and anti-histone antibodies, while anti-Smith antibodies were negative. Although SLE was initially suspected based on serologies, no clinical signs or symptoms were present to fulfill the diagnosis criteria. A trial of oral prednisone resulted in decreased pleural effusion size with no further recurrence. Additional studies included a CT scan of the chest that showed pleural masses confirmed with biopsy to be epithelioid mesothelioma. Given the patient's age and new diagnosis of malignant mesothelioma, we hypothesized that the presence of autoantibodies was likely false positives due to acquired autoantibodies with age, hyperactivity of the immune system from malignancy, and possible prior asbestos exposure.

In plain English

This article reports one patient's case and discusses earlier published reports. A 75-year-old Caucasian man who had never smoked had one month of worsening shortness of breath. A chest X-ray showed a moderate-to-large fluid collection around the right lung (pleural effusion). Three liters of fluid were drained. The fluid tested negative for cancer and bacteria, but it returned within a week. Blood tests were positive for antinuclear antibodies, low-level anti-double stranded DNA antibodies (15 IU/mL) and anti-histone antibodies (2.5 Units). These markers are linked to systemic lupus erythematosus (SLE). Anti-Smith antibodies were negative, and he had no typical SLE symptoms. After a week of prednisone, the effusion was smaller. A CT scan then showed multiple pleural masses, and a biopsy was consistent with epithelioid mesothelioma. He at first denied asbestos exposure but later mentioned possible exposure during military service. The authors suggested the antibodies could be false positives or attributable to the cancer. They could not exclude a contribution from his prior asbestos exposure.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report of a single patient, with a discussion of the published literature (the two earlier reported cases described in the discussion are other authors' reports, not this study's findings)
• Who was studied: One 75-year-old Caucasian man with essential hypertension and past prostate cancer treated by prostatectomy, a lifetime nonsmoker, seen at Creighton University, Omaha, USA (dates of care not stated)
• Exposure: Possible asbestos exposure during military service, mentioned by the patient after he had first denied asbestos and silica exposure; no fiber type, job details or dose given
• Main results:
  • Three liters of pleural fluid were removed. The fluid was exudative and negative for malignancy and for bacterial growth. It reaccumulated one week later.
  • The patient's blood was positive for antinuclear antibodies (qualitative screen) and showed low-titer anti-double stranded DNA antibodies at 15 IU/mL (normal range 0.0 to 4.0 IU/mL).
  • The patient's anti-histone antibodies were moderately positive at 2.5 Units (normal range 0.0 to 0.9 Units). Rheumatoid factor was 16 IU/mL.
  • Anti-Smith and anti-CCP antibodies were absent. Complement C3 and C4 levels and urinalysis were normal.
  • The patient denied the classic systemic symptoms of SLE (joint pain, joint swelling, skin rash, Raynaud's phenomenon).
  • After oral prednisone 30 mg daily for seven days, a repeat ultrasound one week later showed a smaller pleural effusion.
  • A chest CT showed multiple pleural masses, including a 7.8 cm x 2.4 cm lobulated mass in the right upper lobe, suggestive of possible pleural mesothelioma.
  • Bronchoscopy with lung biopsy was consistent with epithelioid mesothelioma.
• The authors' conclusion: The authors concluded that malignant mesothelioma has been associated with positive rheumatologic markers without any underlying rheumatologic disorder, and that a broad differential diagnosis is needed. In this patient they considered the anti-dsDNA and anti-histone antibodies possibly false positives or attributable to the cancer. They could not exclude a contribution from prior asbestos exposure.
• Limitations the authors state:
  • Only a qualitative antinuclear antibody screen was done, not a quantitative titer, so the positive result was nonspecific.
  • The cause of the positive anti-histone antibodies remained unclear.

Topics

Medical terms in this study, explained in our Lexicon: Malignant Mesothelioma, Chest X-Ray, Pleural Effusion, Thoracentesis, CT Scan, Biopsy, Epithelioid, Mesothelioma.

Related studies

• A second case of pericardial mesothelioma mimicking systemic lupus erythematosus in the literature in over 30 years: a case report — C. Mensi, A. Romano, et al. (2017)
• Occupational exposures and risk of systemic lupus erythematosus — C.G. Parks, G.S. Cooper (2005)
• Asbestosis and systemic lupus erythematosus — P. Bartsch, J. Salmon, et al. (1980)
• Metastatic pleural mesothelioma presenting with solitary involvement of the tongue: report of a new case and review of the literature — F. Zanconati, A. DelConte, et al. (2003)
• Malignant mesothelioma presenting as recurrent hydro-pneumothorax: An atypical case presentation and literature review — N. Sattar, R. Durrance, et al. (2018)
• Occupational exposures in rare cancers: A critical review of the literature — B. Charbotel, B. Fervers, et al. (2014)

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