Rheumatoid Lung Disease

Jason Hostetter

Patient 1 - 48 year old woman

Patient 1 - 48 year old woman

Patient 2 - 67 year old man

Patient 2 - 67 year old man

Patient 2 - 67 year old man

Epidemiology


  • RA 1% prevalence
    • more common in women (3:1)
  • pleuropulmonary manifestations 40-75%
    • more common in men (5:1)
    • 2nd most common cause of death (18%) after infection

Pleural Disease


  • pleural thickening or effusion most common thoracic manifestation
    • effusions in 3-5% of pts, usually during flares, tend to resolve spontaneously
      • 80% male, 80% had rheumatoid nodules
      • almost all > 35 yrs old

Pneumothorax

  • Uncommon
  • possibly due to caviation of subpleural necrobiotic nodule
  • may develop spontaneous sterile empyema, bronchopleural fistula (rare)

Large Airways


  • Cricoarytenoid arthritis
  • Bronchiectasis

Rheumatoid nodules

  • increased incidence:
    • men
    • smokers
    • high RF2 titers

Nodules

  • well circumscribed
  • in lung, pleura, or pericardium
  • freq subpleural, usually multiple
  • cavitation in 50%, rarely calcified
  • identified in < 1% of chest x-rays

  • histology:
    • central zone of fibrinoid necrosis surrounded by palisading histiocytes

Rhematoid lung nodule


Nodules

  • Usually benign
  • Nonspecific, improvement during steroid treatment or regression with time may aid diagnosis
  • may be active on PET

Caplan's syndrome

  • assoc of rheumatoid nodules with pneumoconioses
  • peripheral nodules appear with crops of subcutaneous nodules during RA flare
  • biopsy shows inorganic dust within necrotic nodule
  • no treatment necessary

Airway and interstitial disease

  • strong assoc between RA and obstructive airway dz

  • Most common radiographic finding:
    • basal linear markings and focal infiltrate

  • CT findings:
    • bronchiectasis and bronchiolectasis in 30%
    • tree-in-bud

Obliterative bronchiolitis

  • rare
  • women with well-established RA
  • dry cough and rapidly progressive dyspnea
  • poor prognosis
  • CXR may be normal
  • HRCT shows geometric mosaic attenuation
    • expiratory scans confirm air trapping

Obliterative bronchiolitis


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177462/

Interstitial lung disease

  • Associated with three CT patterns:
    • UIP
    • NSIP
    • organizing pneumonia

UIP


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177462/

NSIP


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177462/

Organizing pneumonia


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177462/

Drug induced lung disease

  • Methotrexate induced acute interstitial pneumonitis
    • 1-5% of patients
    • subacute, progressive cough, dyspnea and fever
    • CXR:
      • diffuse bilateral, basal interstitial or alveolar infiltrate
      • LA or pleural effusions may suggest this diagnosis
    • CT:
      • NSIP pattern

Methotrexate induced lung disease


References

  • Sidhu HS, Bhatnagar G, Bhogal P, Riordan R. Imaging Features of the Pleuropulmonary Manifestations of Rheumatoid Arthritis: Pearls and Pitfalls. J Clin Imaging Sci 2011;1:32 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177462/)
  • Joseph J. Chena, Barton F. Branstetter IV, Eugene N. Myers. Cricoarytenoid Rheumatoid Arthritis: An Important Consideration in Aggressive Lesions of the Larynx. AJNR 2005 26: 970-972 (http://www.ajnr.org/content/26/4/970.full) 
  • D.E. Hilling, P.M. van den Berg, A.C. Makkus, F. van der Straaten, P.W. Plaisier: Recurrent Pneumothorax In A Patient With Rheumatoid Arthritis On Leflunomide Treatment: Case Report And Overview Of The Literature. The Internet Journal of Rheumatology. 2007 Volume 3 Number 1. DOI: 10.5580/4c3
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