Fig. 4.

Ruptured necrobiotic nodules complicated by hydropneumothorax and empyema. 35-year-old female with rheumatoid arthritis. (a) CT. A ruptured subpleural necrobiotic nodule in the right lower lobe (white arrowhead) with associated small hydropneumothorax (black arrowhead). (b) CT few weeks later. Formation of bronchopleural fistula adjacent to the necrobiotic nodule (black arrow). (c) CT few weeks later following chest tube drainage, open thoracotomy and talc pleurodesis (white arrow). Enlarging hydro-pneumothorax (black arrowheads) secondary to underlying bronchopleural fistula and marked pleural thickening due to empyema resistant to treatments.

Teaching point: Subpleural location of cavitary necrobiotic rheumatoid nodules predisposes the patient to recurrent pneumothoraces and infection within the pleural space.