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A 53-Year-Old Woman Is Evaluated for Fatigue, Malaise, and Exertional

question 797

Multiple Choice

A 53-year-old woman is evaluated for fatigue, malaise, and exertional shortness of breath. She describes a dry cough that has been present over the last year and frequent joint pain and swelling in her hands and wrists. She has no other medical problems and is a lifetime non-smoker. The patient emigrated from Ecuador 3 months ago. Tuberculosis and HIV testing done for immigration screening 6 months ago were normal.
Vital signs are within normal limits. Her body mass index is 20 kg/m². There is a 2/6 mid-systolic murmur at the right upper sternal border. Breath sounds are decreased at the right lung base. There are no skin rashes or peripheral edema. The patient has mild synovitis involving bilateral metacarpophalangeal joints.
Her hemoglobin is 10.2 g/dL and mean corpuscular volume is 85 fL. Chest x-ray shows a moderate right-sided pleural effusion. Thoracentesis shows yellow-greenish fluid with the following results:

Which of the following is the most likely cause of this patient's pleural effusion?

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