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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 853-855
Rheumatoid arthritis-related lung disease-- a case report


Department of Radio-Diagnosis and Imaging, J.J.M. Medical College, Davangere - 577 004. Karnataka, India

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Date of Submission31-Oct-2006
Date of Acceptance10-Nov-2006
 

Keywords: Arthritis, Rheumatoid. Lung, interstitial disease.

How to cite this article:
Patil A K, Hegde K K. Rheumatoid arthritis-related lung disease-- a case report. Indian J Radiol Imaging 2006;16:853-5

How to cite this URL:
Patil A K, Hegde K K. Rheumatoid arthritis-related lung disease-- a case report. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 24];16:853-5. Available from: http://www.ijri.org/text.asp?2006/16/4/853/32366

   Introduction Top


Rheumatoid lung is a frequent extra-articular manifestation found in 2 - 54% of patients with rheumatoid arthritis [1], occasionally being apparent before joint disease [2].Pulmonary disease presents more commonly in males than in females in the ratio of 5:1 although RA is much more common in females [1].The Onset is most frequent during the 4th -5th decades of life [3].

We report a case of rheumatoid lung in a 30 year old man and discuss the plain radiograph and CT features of the condition. Collagen vascular disease. Pulmonary nodule.


   Case report Top


A 30 year old man, a known case of rheumatoid arthritis, presented with cough with expectoration, haemoptysis and Grade III breathlessness. On examination, harsh vesicular breath sounds were heard. Ronchi and basal crepitations were heard bilaterally.

Serological Investigations:

Anti Nuclear Antibodies against deoxyribonucleoprotein was 'POSITIVE'. Rheumatoid factor: 56.1 U/L [Normal 0-20 U/L]. "POSITIVE". Pleural Fluid aspiration analysis:

20ml of hemorrhagic fluid

Protein: 2.84 grams / dl.

Glucose: 75.0 mg / dl.

Plain Frontal Chest Radiograph showed bilateral, multiple, well defined rounded opacities of varying sizes and bilateral pleural effusion [Figure 1).

CT scan of the thorax showed multiple well defined nodular lesions of varying sizes, distributed predominantly in peribronchovascular and sub-pleural locations in both lung fields with surrounding reticulations. Few nodules showed central low attenuation areas suggestive of necrosis (Figure 2],[Figure - 3],[Figure - 4].


   Discussion Top


Rheumatoid arthritis is a chronic multi-system disease of unknown etiology probably resulting from the exposure of a genetically predisposed individual to some infectious agents. HLA-DR4 and related alleles are known major genetic risk factors for RA [3]. It usually manifests as chronic inflammatory arthritis of multiple joints and associated with a wide variety of pleuro-pulmonary abnormalities like pleural effusion / pleuritis, rheumatoid lung nodules, diffuse interstitial pneumonia, lymphoid hyperplasia, pulmonary vasculitis and airway disease (bronchiectasis, bronchiolitis obliterans and follicular bronchiolitis) [4].

Pathologically 5 different groups were identified on the basis of histological pattern namely -
" Rheumatoid pulmonary nodules
" Usual interstitial pneumonia.
" BOOP(Bronchiolitis obliterans, organizing pneumonia)
" Lymphoid hyperplasia
" Cellular interstitial infiltrates [4].

In rheumatoid necrobiotic nodule a central zone of eosinophilic fibrinoid necrosis is surrounded by palisading fibroblasts, the nodule often being centered on necrotic inflamed blood vessel [1].

Clinically presents with cough with expectoration, hemoptysis, exertional dyspnea and nocturnal wheezing.

Laboratory analysis shows rheumatoid factors, which are auto antibodies reactive with the Fc portion of Ig, found in more than 2/3rds of adults with the disease, however it is non-specific [3].

Pulmonary function tests show airway obstruction (decreased FEV1/VC) or small airway disease (decreased FEF25-75) [5].

Plain radiograph of chest is non specific and shows pleural effusion / thickening, necrobiotic nodules, diffuse interstitial fibrosis, caplans syndrome and pulmonary hypertension [6].

CT helps in identifying the lesions (Reticulations, ground glass opacity, honey combing, lung nodules, consolidation, bronchiectasis, air trapping, pleural effusion/thickening, lymph node enlargement, pulmonary artery enlargement) and categorizing the findings into major CT patterns, namely- usual interstitial pneumonia, non specific interstitial pneumonia, bronchiolitis and organizing pneumonia [7].

However the nature of the nodules cannot be determined from clinical or radiographic findings alone. A lung biopsy is needed to establish the diagnosis [8].

Differential diagnosis of pulmonary nodules and underlying lung disorders in a patient with RA include- mycobacterial infections, non-mycobacterial infections (Nocardia, Cryptococcus, histoplasma, aspergillus), neoplasms (bronchoalveolar carcinoma, multiple myeloma, lymphoma) and other collagen vascular diseases like SLE, systemic sclerosis, multiple connective tissue diseases, polyarteritis nodosa, dermatomyositis / polymyositis [8].

Treatment remains largely empirical to reduce inflammation, relieve pain and to control systemic involvement [3].

 
   References Top

1.Wolfgang Dahnert. Chest disorders. Radiology Review Manual. 2003; 5th Edt:521-522.  Back to cited text no. 1    
2.David Sutton, Simon P.G.Padley, Michael.B.Rubens.Diffuse lung disease.Text Book of Radiology and Imaging.2003, 7th; Edt; 197-199.  Back to cited text no. 2    
3.T.R.Harrisons, Peter.E.Lipsky.Rheumatoid arthritis. Principles of Internal Medicine.2001; 15th Edt: 1928-1937.  Back to cited text no. 3    
4.Eun A Kim, Kyung Soo Lee, Takeshi Johkoh, et al.Interstitial Lung Diseases Associated with Collagen Vascular Diseases: Radiologic and Histopathologic Findings.Radiographics.2002; 22:S151-S165.  Back to cited text no. 4    
5.Thierry Perez, Martine Remy-Jardin, Bernard Cortet.Airway involvement in Rheumatoid arthritis. Am J of Resp and Critical care medicine.1988;157:5:1658-1665.  Back to cited text no. 5    
6.Lee Sider.Radiology of the chest. Introduction to diagnostic imaging.1986:60-61.  Back to cited text no. 6    
7.Nobuyuki T, Jerry S.K, K.K.Brown, et al.Rheumatoid arthritis related lung Disease: CT Findings.Radiology.2004; 232:81-91.  Back to cited text no. 7    
8.Nancy Lee Harris, William F McNeely, Jo Anne Shepard. Case - 10-2001-A 53 yr old woman with arthritis and pulmonary nodules. The new England J of Medicine.2001; 344:13:997-1004.  Back to cited text no. 8    

Top
Correspondence Address:
K K Hegde
Hegde Diagnostic Centre, C.G.Hospital Road, P.J.Extension, Davangere-577 004. Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32366

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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