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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 835-839
"Interstitial Lung disease (Ild) in Rheumatoid arthritis (Ra)"- a study of thirty cases


Department of Radiodiagnosis,V S HOSPITAL, Ellisbridge , Ahmedabad- 380016, India

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Date of Submission29-May-2005
Date of Acceptance10-Aug-2006
 

   Abstract 

Objectives- The objective of this study is to evaluate the Interstitial Lung Disease (ILD) in the patients with Rheumatoid Arthritis (RA) and to correlate clinico - spirometric profile and High Resolution Computed Tomography (HRCT) findings with regards to early detection of possible lung involvement in the study group. Materials and Methods The present study was carried out at Shree Sayajirao General Hospital (SSGH), Baroda from January 2002 to December 2002. The patients satisfying the American College of Rheumatology (ACR) criteria [1] for RA were included in this study, without regards to the presence of pulmonary symptoms or chest x-ray changes. None of our patient was on Disease Modifying Anti-Rheumatic Drugs (DMARD) therapy. All thirty patients (seven males and twenty three females) - underwent clinical, spirometric, laboratory, x-ray chest and HRCT evaluation of lung. Diagnosis of ILD was confirmed by HRCT and supported by clinical and physiological findings in all patients. All the gathered information and investigations were subjected to statistical analysis. Results Majority of the patients had duration of illness between one and three years. The mean duration of illness was 2.9 years. RA factor was positive in 25 patients (83.3%). Six of the thirty patients had respiratory complaints (20%). Spirometric evidence of lung involvement was present in eight patients (26.6%). Only four of them had abnormalities detectable on chest radiograph (13.33%). HRCT was abnormal in eleven patients (36%). Conclusion In concluding the results of our study, the interstitial lung changes affects significant proportion (36%) of the patients affected with RA. Overall, HRCT is the most sensitive parameter to detect the early interstitial changes in patients with RA. HRCT can show evidence of interstitial lung changes even when clinical and pulmonary function tests parameters are normal. HRCT is superior to plain chest radiograph in the evaluation of early interstitial lung changes associated with RA. Coexisting subcutaneous rheumatoid nodules is a high-risk factor for development of ILD in patients with RA.

Keywords: Interstitial lung disease, Rheumatoid arthritis, High-resolution computed tomography

How to cite this article:
Raniga S, Sharma P, Kaur G, Arora A, Khalasi Y, Vohra P V. "Interstitial Lung disease (Ild) in Rheumatoid arthritis (Ra)"- a study of thirty cases. Indian J Radiol Imaging 2006;16:835-9

How to cite this URL:
Raniga S, Sharma P, Kaur G, Arora A, Khalasi Y, Vohra P V. "Interstitial Lung disease (Ild) in Rheumatoid arthritis (Ra)"- a study of thirty cases. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 22];16:835-9. Available from: http://www.ijri.org/text.asp?2006/16/4/835/32362

   Introduction Top


Following its description by Ellmann and Ball [2], ILD quickly appeared as the predominant pulmonary manifestation of Rheumatoid Arthritis (RA) (after excluding drug-induced pulmonary disease) [3].

RA is an autoimmune disease of unknown pathogenesis. The predominant extra-articular manifestations include subcutaneous nodules, pleuro-pulmonary, cardiac and neurological involvement, vasculitis and Felty's syndrome [4].

Pleuro-pulmonary involvement is an important cause of morbidity and mortality in the patients of RA [5],[6]. Pulmonary involvement is frequent in the course of rheumatological diseases, and may be due to various causes including infection, drug toxicity and specific manifestations of the immune process [7],[8]. The purpose of our study was to present our experience to evaluate HRCT findings in RA & know its clinical utility.


   Materials and Methods Top


The present study was carried out at Shree Sayajirao General Hospital (SSGH), Baroda, Gujarat, India from January 2002 to December 2002. The study was prospective. The patients satisfying the American College of Rheumatology (ACR) criteria [1] for RA were included in this study, without regards to the presence of pulmonary symptoms or chest x-ray changes. All thirty patients (seven males and twenty three females) - underwent clinical, spirometric, laboratory, x-ray chest and HRCT evaluation of lung.

All patients underwent HRCT (Philips Tomoscan, Best, Netherlands) examination. Scanning time was 2 s. Supine and prone views were taken. Serial slices 2 mm in width and 10 mm apart were taken from the apex of the lung to base and reconstructed on a High-resolution bone algorithm. All images were obtained at window levels appropriate for lung parenchyma settings (window width 1300 HU; window level -600 HU). Prone images were obtained in the patients to differentiate dependent opacity from early interstitial lung changes. A chest radiograph was taken at the same time as the HRCT scan. HRCT scans were interpreted by two consultant radiologists- A ground glass opacity (GGO) was defined as a patchy or diffuse increase in lung density that did not obscure pulmonary vasculature. Finding consistent with Interstitial Lung disease (ILD) was defined as the presence of GGO, IPF (Honeycombing, traction bronchiectasis, or interlobular septal thickening. All the gathered information and investigations were subjected to statistical analysis.


   Results Top


The present study comprised of thirty cases of RA. There were seven males (23.33%) and twenty-three females (76.67%). The male to female sex ratio was 1:3. Average age of male patients was 48.4 years and for females 45.8 years. Majority of the patients had duration of illness between one and three years. The mean duration of illness was 2.9 years. RA factor was positive in twenty-five patients (83.3%).

Six of the thirty patients had respiratory complaints (20%). The symptoms include cough, breathlessness, wheeze, sputum production and chest pain. Only three patients (10%) had clinical evidence of respiratory involvement in form of rhonchi and crackles.

Patients with rheumatoid nodules were more likely to have lung involvement. In our study population, three patients with rheumatoid nodules had HRCT findings consistent with ILD and no patient without lung involvement had rheumatoid nodule. Spirometric evidence of lung involvement was present in eight patients (26.6%). Thus, spirometric abnormalities could be detected in asymptomatic patients also. Only four of them had abnormalities detectable on chest radiograph (13.33%) - including bilateral reticular infiltrates (FIG. 1) in three and honeycombing in one. HRCT was abnormal in eleven patients (36%) and hence more sensitive than chest radiograph and spirometry to detect pleuropulmonary involvement in patients of RA.

It is evident from Table 1 that chest radiograph is the least sensitive with only four out of thirty patients shows findings consistent with interstitial disease. HRCT shows evidence of interstitial lung disease in eleven out of thirty patients and so the most sensitive of all parameters.

Table 2 shows that out of 30 patients, eighteen patients had no abnormality in any of the parameters related to the pulmonary involvement. Two patients (6.66%) showed HRCT findings consistent with ILD in the absence of clinical, spirometry or chest radiographic changes. Three (10%) patients showed HRCT findings consistent with ILD without clinical or radiographic changes. Six patients (20%) had HRCT findings consistent with ILD in the absence of clinical findings consistent with pulmonary involvement. Three (75%) of the four patients with chest radiograph consistent with interstitial lung disease had relevant clinical symptoms. Only one patient (3.33%) had clinical findings and spirometry consistent with pulmonary involvement did not have HRCT abnormality.


   Discussion Top


Rheumatoid Arthritis (RA) is a connective tissue disease characterized by symmetrical inflammatory arthritis. It is the most common of the connective tissue diseases. The majority of patients have extra-articular disorders. RA is associated with a broad spectrum of pleural and pulmonary manifestations. Most, but not all, patients with pleuropulmonary disease have other clinical evidence of RA. In a significant minority of patients, pleuropulmonary disease antedates the development of arthritis [9].

RA is a chronic multisystem disease of unknown etiology that affects 1% of the population, with a 3:1 predilection for women between the ages of twenty and fifty years [10]. The classic clinical manifestation is chronic symmetric polyarthritis due to a persistent inflammatory synovitis, but is also associated with other systemic findings that can affect virtually any body tissue or organ. The predominant extra-articular manifestations include subcutaneous nodules, pleuro-pulmonary, cardiac and neurological involvement, vasculitis and Felty's syndrome [4]. The course of the extra articular manifestations of RA does not go always parallel to the disease of the joints [9]. Coexisting subcutaneous rheumatoid nodules, high titers of circulating rheumatoid factor or antinuclear antibodies are considered significant risk factors for the development of ILD in patients with RA. Incidence of ILD appears unrelated to the severity of articular disease, male sex, nodular disease, extra-articular disease, longer disease duration, or disease severity [11].

Pleuro-pulmonary involvement is an important cause of morbidity and mortality in the patients of RA [9]. Most frequent radiographic manifestation is pleural effusion which can be unilateral or bilateral and is usually small or moderate in size [12]. RA is commonly associated with thoracic abnormalities, including ILD, pleural thickening and effusion, necrobiotic nodules, Bronchiolitis Obliterans Organizing Pneumonia (BOOP), bronchiectasis and Bronchiolitis obliterans [5],[6].

Pulmonary fibrosis occurs in 19% of patients with RA irrespective of respiratory symptoms, however, early interstitial lung changes and subclinical alveolitis have been found in up to 40% of RA patients [13],[14],[15],[16],[17]. Mean age at lung disease onset is the fifth or sixth decade [18]. Genetic factors have also been described. Relative risk of ILD is markedly increased in patients with non-M1M1 1-antitrypsin phenotypes [19],[20]. Arthritis precedes the development of ILD in approximately 90% of affected patients [18]. Presence of ILD may have an important impact on the prognosis [21],[22]. HRCT chest has been proposed and accepted as the standard non-invasive method of diagnosing and following ILD in patients with RA [23],[24]. The results of HRCT have been shown to correlate closely with those of open lung biopsy in connective tissue disorders, although less well with pulmonary function tests [23],(25).

Histologically, majority of patients who have ILD associated with RA have Usual Interstitial Pneumonia followed by peribronchovascular and interlobular lymphoid hyperplasia [18]. Chest HRCT scanning has been shown to correlate with lung biopsy findings in up to 93% of cases (26). Pulmonary Function Tests detects a decreased diffusing capacity in 41% of patients, and among them, 50% exhibited features of fibrosis associated with lymphoid infiltrates in lung biopsy [18].

Evidence of interstitial fibrosis is seen at chest radiography in approximately 5% of patients with rheumatoid arthritis and at HRCT in 30%-40% [5],[6],(27),(28). The chest radiograph may be normal in patients with early fibrosis. In late stages, chest radiograph shows changes identical to that of Interstitial Pulmonary Fibrosis (IPF) (29). Chest radiographs typically show a fine reticular or reticulonodular pattern involving the lower lung zones in early stages. With progression of disease, the reticular pattern becomes more coarse and diffuse, and honeycombing may be seen [18],(30).

HRCT is the gold standard for diagnosis of ILD (31). On HRCT, the appearance of RA with interstitial fibrosis is usually indistinguishable from that of IPF and includes traction bronchiectesis, intralobular septal thickening, irregular interlobular septal thickening, irregular interfaces, honeycombing, Ground Glass Opacities (GGO), peripheral and subpleural predominance of fibrosis or GGO, lower lung zone and posterior predominance, pleural thickening and effusion (FIG 2) (32),(33). Honeycombing is seen less commonly than in IPF; however predominant GGO is seen more commonly in patients with RA (32). Evidence of GGO as a predominant finding in the absence of honeycombing is associated with active alveolitis. This is usually considered a feature of early and potentially reversible disease (34). Radiographically abnormalities are indistinguishable from ILD caused by other diseases. Progression to end-stage fibrosis results in the classical honeycombing pattern (FIG 3).

Coexisting pleural effusion is common [18]. HRCT is much more sensitive than plain chest radiography in the assessment of ILD and its higher sensitivity should allow an earlier diagnosis [18]. The coexistence of airway thickening and dilatation outside the fibrotic area is also highly suggestive of RA [18]. HRCT shows similar lesions, including GGO, basal honeycombing, traction bronchiectasis and emphysema [23],(35),(36). Other changes of RA on HRCT include BOOP, bronchiectasis and bronchial disease, consolidation, enlarged lymph nodes and nodules that are predominantly subpleural in location (28),(32). Bronchiectasis is seen in up to a third of patients [1].

Chest x-ray showed changes consistent with ILD in 9/150 (6%) patients with RA and X-ray chest was normal in 18/28 (64.2%) patients with HRCT positive ILD [9]. In our study, chest x-ray showed changes consistent with ILD in 4/30 (13.3%) and x-ray chest was normal in 7/11 (63.6%) patients with HRCT positive ILD.

HRCT was able to detect interstitial pneumonitis in 17/29 RA patients with a normal chest radiography (37). In our study, HRCT findings consistent with ILD were seen in seven patients with normal chest radiography.

Four prospective studies in RA population have reported a prevalence of ILD of 19-44% [2],[17],(27),(38). The reason for the variability in the prevalence of ILD is the terminology used by different authors. The HRCT appearance in keeping with ILD encompasses a variety of abnormalities including interstitial fibrosis thickening of non-septal and septal lines, ground glass attenuation honeycombing and traction bronchiectasis [2],[17],[18],(38),(39).

The HRCT study by Fewins et al [17] of patients with RA revealed a high prevalence of ILD (44%). If all forms of our HRCT diagnosed ILD that is, changes of IPF, GGO and interlobular thickening are combined, there is a closer level of prevalence (37%) of ILD to that study [11]. Our study showed 36% prevalence of ILD in RA.

McDonagh et al [23] found that RA patients with evidence of ILD have abnormalities on HRCT which cannot be confidently predicted on any other non-invasive test. Pulmonary function tests were generally poor predictors of HRCT findings [23]. HRCT findings consistent with ILD were seen in eleven out of thirty patients (36%), compare to the spirometric findings in 8/30 (26.6%). Four patients (13.3%) with HRCT findings consistent with ILD did not show any abnormality on pulmonary function test. The results of HRCT have been shown to correlate closely with those of open lung biopsy in other connective tissue disorders, although less well with pulmonary function tests [16],[17].


   Limitations of the study Top


Recruitment of patients could introduce some bias through selection of patients with somewhat more severe articular involvement than that in the overall RA population. Histopathological correction is not done in study population, which is considered gold standard for the diagnosis of interstitial lung disease though being invasive. However, the purpose of our study was to compare clinico-spirometric profile, x-ray and chest HRCT scan which is now the gold standard non-invasive test for evaluation of ILD [23].


   Conclusions Top


In concluding the results of our study, the interstitial lung changes affects significant proportion (36%) of the patients affected with RA. Overall, HRCT is the most sensitive parameter to detect the early interstitial changes in patients with RA. HRCT can show evidence of ILD even when clinical and pulmonary function tests parameters are normal. HRCT is superior to plain chest radiograph in the evaluation of early interstitial lung changes associated with RA. Coexisting subcutaneous rheumatoid nodules is a high-risk factor for development of ILD in patients with RA. When investigating dyspnoea in patients with RA, abnormalities on chest examination or pulmonary function tests, even without restrictive changes or chest radiographic abnormalities should prompt physicians to request a chest HRCT scan.

 
   References Top

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2.Tanoue LT. Pulmonary manifestations of rheumatoid arthritis. Clin Chest Med 1998; 19:667-685.  Back to cited text no. 2    
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14.Kelly CA. Rheumatoid arthritis, classical lung disease. Bailliere's Clin Rheumatol 1993; 7:1-16.   Back to cited text no. 14    
15.Fewins HE, McGowan I, Whitehouse GH, Williams J, Mallya R. High definition computed tomography in rheumatoid arthritis associated pulmonary disease. Br J Rheumatol 1991; 30:214-216.   Back to cited text no. 15    
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Correspondence Address:
S Raniga
15, Amrakunj Society,B/h Nehrunagar, S. M. Road,Ambawadi, Ahmedabad-380015
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32362

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