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Aryeh Fischer, MD; Sterling G. West, MD; Jeffrey J. Swigris, DO, MS; Kevin K. Brown, MD; Roland M. du Bois, MD
Author and Funding Information

From the Interstitial and Autoimmune Lung Disease Program (Drs Fischer, Swigris, Brown, and du Bois), National Jewish Health, and the Division of Rheumatology (Drs Fischer and West), National Jewish Health and University of Colorado.

Correspondence to: Aryeh Fischer, MD, 1400 Jackson St, Denver, CO 80206; e-mail: fischera@njhealth.org


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.

Dr du Bois is currently at Imperial College (London, England).

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):723. doi:10.1378/chest.10-2537
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To the Editor:

We appreciate the support of Teramoto and colleagues for the concepts outlined in our recent commentary in CHEST (August 2010),1 which include the importance of a multidisciplinary approach to evaluating interstitial pneumonia (IP) and emphasize the usefulness of specific autoantibodies, such as anti-cyclic citrullinated peptide (CCP), as part of the assessment for connective tissue disease-associated interstitial lung disease (CTD-ILD). Teramoto and colleagues also briefly describe a patient without synovitis who presented with organizing pneumonia and anti-CCP antibody positivity, who later developed the articular manifestations of rheumatoid arthritis (RA). In our and others’ experience,2 this is not an uncommon scenario, and it supports the notion that lung disease may be the first manifestation of a CTD and that surveillance for evolving extrathoracic features is needed when caring for patients with “idiopathic” IP. Interestingly, we have recently identified a sizable cohort of patients with anti-CCP positivity and IP without prior history of CTD or the articular features of RA.3 Although a few of these patients have developed the synovitis of RA within a short interval of follow-up, the vast majority have not. Because these patients with ILD have a highly specific autoantibody in the absence of defining extrathoracic CTD features, and because without inflammatory arthritis they cannot be defined as having RA, we have proposed that it is important to distinguish them from the category of idiopathic IP and consider them to have lung-dominant CTD.1 With prospective assessments of these types of more precisely characterized and classified phenotypes, we hope that important questions regarding their pathobiology, natural history, and therapeutic responsiveness will be answerable. Finally, we emphasize that a classification of lung-dominant CTD conveys that this entity is distinct from both idiopathic IP and from definite CTD-ILD and that these patients require surveillance for evolution to more defined forms of CTD.

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]
 
Gizinski AM, Mascolo M, Loucks JL, et al. Rheumatoid arthritis (RA)-specific autoantibodies in patients with interstitial lung disease and absence of clinically apparent articular RA. Clin Rheumatol. 2009;285:611-613. [CrossRef] [PubMed]
 
Solomon JJ, Stevens A, Gill M, et al. Anti-CCP positivity in patients with lung disease but no apparent articular RA: a pre-RA state? Arthritis Rheum. 2010;6210S:S886-S887. [CrossRef]
 

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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]
 
Gizinski AM, Mascolo M, Loucks JL, et al. Rheumatoid arthritis (RA)-specific autoantibodies in patients with interstitial lung disease and absence of clinically apparent articular RA. Clin Rheumatol. 2009;285:611-613. [CrossRef] [PubMed]
 
Solomon JJ, Stevens A, Gill M, et al. Anti-CCP positivity in patients with lung disease but no apparent articular RA: a pre-RA state? Arthritis Rheum. 2010;6210S:S886-S887. [CrossRef]
 
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