0
Correspondence |

A Clue to Diagnosing Connective Tissue Disease-Associated Interstitial Lung Disease FREE TO VIEW

Shinji Teramoto, MD, FCCP; Kosaku Komiya, MD; Shunsuke Akashi, MD; Masahiro Kawashima, MD
Author and Funding Information

From the Department of Respiratory Medicine (Drs Teramoto, Akashi, and Kawashima), National Hospital Organization, Tokyo National Hospital; and the Department of Respiratory Medicine (Dr Komiya), Oita University Hospital.

Correspondence to: Shinji Teramoto, MD, FCCP, Department of Respiratory Medicine, National Hospital Organization, Tokyo National Hospital, 3-1-1 Takeoda, Kiyose, Tokyo, Japan; e-mail:shinjit-tky@umin.ac.jp


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(3):722. doi:10.1378/chest.10-2381
Text Size: A A A
Published online

To the Editor:

In a recent issue of CHEST (August 2010), Fischer and coworkers1 discussed the dilemmas surrounding the classification of a patient with interstitial pneumonia (IP) whose clinical features suggested an associated connective tissue disease (CTD) but did not provide a clear diagnosis of CTD-associated interstitial lung disease (ILD) on the basis of current rheumatologic classification systems. Undeniably, current rheumatologic classification schemes are limiting because they do not allow CTD designation when IP is the lone manifestation. We agree with the authors that the detection of occult CTD in patients presenting with IP is optimized by multidisciplinary collaboration. It is very difficult to differentiate idiopathic pulmonary fibrosis from CTD-ILD before the appearance of their systematic manifestations. However, several autoantibodies have been identified as being of diagnostic significance for CTD and may serve as clues for a new CTD-ILD classification.

We recently reported an elderly woman who presented with organizing pneumonia; anticyclic citrullinated peptide (anti-CCP) antibody positivity was the first manifestation of rheumatoid arthritis (RA).2 Although she did not exhibit articular symptoms initially, representative RA manifestations developed 8 months later. Thus, anti-CCP antibody positivity may be a good indicator for RA-ILD diagnosis.2 Anti-CCP antibodies are reportedly the best predictors of RA activity3; they can be detected very early in the disease and have been reported to predict erosive RA development.4 ILD as the first presentation of CTDs, particularly in RA, is rare5; therefore, the examination of these antibodies may be important for the differential diagnosis of CTD-ILD.

We also agree with the authors that specific antibodies are integral in CTD-ILD assessment, and practitioners should apply certain indicators in addition to antinuclear antibody and rheumatoid factor for more effective screening for CTD. In particular, anti-Scl-70, anti-tRNA synthetase antibodies (eg, Jo-1, PL-7, and PL-12), anti-Ro (SS-A), antiribonucleoprotein, and anti-CCP are highly specific to CTDs.6,7 The selection of the autoantibodies is critical for CTD-ILD diagnosis. The disease-specific antibodies should be examined extensively and carefully.

Although the symptoms and extrapulmonary manifestation are not always specific for CTDs, an initial basic examination is important. The diagnostic and therapeutic outcomes are the ultimate determinants for the differential diagnosis and the further refinement of actual diagnosis. Nonetheless, several autoantibodies specific for CTDs are currently the strongest marker of the diseases and should be used wisely and actively for the early diagnosis and correction of the diagnosis of CTD-ILD.

Fischer A, West SG, Swigris JJ, Brown KK, du Bois RM. Connective tissue disease-associated interstitial lung disease: a call for clarification. Chest. 2010;1382:251-256. [CrossRef] [PubMed]
 
Komiya K, Teramoto S, Kurosaki Y, et al. Organizing pneumonia with a positive result for anti-CCP antibodies as the first clinical presentation of rheumatoid arthritis. Intern Med. 2010;4915:1605-1607. [CrossRef] [PubMed]
 
van der Helm-van Mil AH, Breedveld FC, Huizinga TW. Aspects of early arthritis. Definition of disease states in early arthritis: remission versus minimal disease activity. Arthritis Res Ther. 2006;84:216. [CrossRef] [PubMed]
 
van Venrooij WJ, van Beers JJ, Pruijn GJ. Anti-ccp antibody, a marker for the early detection of rheumatoid arthritis. Ann N Y Acad Sci. 2008;1143:268-285. [CrossRef] [PubMed]
 
Sato T, Fujita J, Yamadori I, et al. Non-specific interstitial pneumonia; as the first clinical presentation of various collagen vascular disorders. Rheumatol Int. 2006;266:551-555. [CrossRef] [PubMed]
 
Fischer A, Swigris JJ, du Bois RM, et al. Anti-synthetase syndrome in ANA and anti-Jo-1 negative patients presenting with idiopathic interstitial pneumonia. Respir Med. 2009;10311:1719-1724. [CrossRef] [PubMed]
 
Fischer A, Meehan RT, Feghali-Bostwick CA, West SG, Brown KK. Unique characteristics of systemic sclerosis sine scleroderma-associated interstitial lung disease. Chest. 2006;1304:976-981. [CrossRef] [PubMed]
 

Figures

Tables

References

Fischer A, West SG, Swigris JJ, Brown KK, du Bois RM. Connective tissue disease-associated interstitial lung disease: a call for clarification. Chest. 2010;1382:251-256. [CrossRef] [PubMed]
 
Komiya K, Teramoto S, Kurosaki Y, et al. Organizing pneumonia with a positive result for anti-CCP antibodies as the first clinical presentation of rheumatoid arthritis. Intern Med. 2010;4915:1605-1607. [CrossRef] [PubMed]
 
van der Helm-van Mil AH, Breedveld FC, Huizinga TW. Aspects of early arthritis. Definition of disease states in early arthritis: remission versus minimal disease activity. Arthritis Res Ther. 2006;84:216. [CrossRef] [PubMed]
 
van Venrooij WJ, van Beers JJ, Pruijn GJ. Anti-ccp antibody, a marker for the early detection of rheumatoid arthritis. Ann N Y Acad Sci. 2008;1143:268-285. [CrossRef] [PubMed]
 
Sato T, Fujita J, Yamadori I, et al. Non-specific interstitial pneumonia; as the first clinical presentation of various collagen vascular disorders. Rheumatol Int. 2006;266:551-555. [CrossRef] [PubMed]
 
Fischer A, Swigris JJ, du Bois RM, et al. Anti-synthetase syndrome in ANA and anti-Jo-1 negative patients presenting with idiopathic interstitial pneumonia. Respir Med. 2009;10311:1719-1724. [CrossRef] [PubMed]
 
Fischer A, Meehan RT, Feghali-Bostwick CA, West SG, Brown KK. Unique characteristics of systemic sclerosis sine scleroderma-associated interstitial lung disease. Chest. 2006;1304:976-981. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543