Teaching Case

A 57year old woman with an active form of rheumatoid arthritis was admitted to the University Hospital for review and initiation of therapy. Previous medical history except RA was unremarkable. The patient had cold manifested with upper tract respiratory symptoms. No cough, dyspnea, fever or weight loss occurred.

The patient was in a good clinical status, without dyspnea or fever, only symtoms of cold. Breathing was alveolar, without pathologic findings. Because of the smoking history a chest radiograph was indicated. During local examination small nodules on the hands and feet were found.
AP joint radiographs showed typical findings for RA. Especially at the hands and feet were bone erosions with disfiguration of the proximal line of carpal bones, heads of metacarpal bones, cystoid hyperlucency in the structure, deepening or concavity of joints and bone degradation. Also soft tissue reaction around affected joints was remarkable.
A PA chest radiograph was done because of a long term smoking history. The radiograph showed accidental finding of ring - like shadows predominantly in the lower lung lobes, their wall was irregular. Effusion, abscess or enlargement of the pulmonary hilus was not found. Heart and mediastinum were normal.
CT examination followed to define the character of th cavitary nodules and to exclude any other pathology. Numerous irregular thin wall cavitary nodules were found. No effusion or lymphadenopathy was detected.
Over time the patient underwent several CT controls and we detected a change in the character of the lesions, mostly growth. No lymphadenopathy or free fluid, no pleural thickening was found at following CT examinations.

Rheumatoid arthritis (RA) is a subacute or chronic inflammatory disease (polyarthropathy) of unknown cause in which the body's immune system attacks joints and other tissues. Onset is usually between 25 and 50years, women are more likely to develop RA than men (3x more). Heavy long - term smoking is a very strong risk factor for RA as well as other lungs affections (cancer most of all).

Primary sites of inflammation are synovial membranes and articular structures. X-rays generally have not been helpful to detect the presence of early rheumatoid arthritis because they cannot show soft tissue. Swelling and pain in the joints occur for at least 6 weeks before a diagnosis of RA is considered. The pattern of joints affected is usually symmetrical. Although RA almost always develops in the wrists and knuckles, the knees and small foot joints are often affected as well. Indeed, many joints may be involved (cervical spine, shoulders, elbows, tips, temporomandibular joint, inner ear). RA does not usually show up in the fingertips, where osteoarthritis is common. Disease is characterized with relapses and remissions.

Extraarticular RA is more common in male’s age 50-60years. Patients are asymptomatic; most have arthritis, positive rheumatoid factor and cutaneous nodules. Lung changes are found in 90% patients. Pulmonary involvement is a serious complication of rheumatoid arthritis and may be seen as airway disease, rheumatoid nodules, interstitial lung disease and pleurisy.
In literature are described a broad range of pathologic features in the lungs. Four predominant CT patterns are: usual interstitial pneumonia (UIP), nonspecific interstitial pneumonia (NSIP), bronchiolitis obliterans (BO) and organizing pneumonia (OP). Ground-glass opacity or reticulation is the most common CT finding. Honeycombing, traction bronchiectasis and architectural distortion also frequently occurred. The multiplicity of CT patterns is commonly seen and might help differentiate these patients from those with idiopathic diffuse lung disease. Necrobiotic pulmonary nodules are well established among the extra-articular manifestations of RA, but their manifestation is rare. The nodules may be solitary or, more commonly, multiple, ranging in size from a few millimeters to 7cm or more. They are well-circumscribed, localized peripheral, predominantly in lower lobes. The nodules may multiply or regress independently of the disease process elsewhere, and during their existence they may calcify or cavitate and even lead to pyopneumothorax. Necrobiotic nodules occur more frequently in men than woman, compared to the female predominance of rheumatoid arthritis.
Differential diagnosis of lung nodules is not easy. Nodules can imitate bronchial carcinoma radiologically and bronchoscopically. In differential diagnosis of tumor can help irregularity inner lining and cavitations only in 10% of lung tumours. Wegener’s granulomatosis shows nodules with frequent cavitation, but pleural effusion and hilar lymph node enlargement is very rare. Also in full-blown form kidneys, nose and paranasal sinuses are involved. Sarcoidosis is commonly associated with some type of reticulonodular lung disease, but can simulate metastatic lung disease.

Treatment is based on steroids and immunosuppressive therapy.

5 years survival is 40%, death is usually caused by infection, respiratory failure, cor pulmonale or amyloidosis.