SESSION TYPE: ILD Case Report Posters
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: We report a case of organizing pneumonia (OP) and positive anti-cyclic citrullinated peptide (anti-CCP) as first manifestations of rheumatoid arthritis (RA) with subsequent progression to pulmonary fibrosis.
CASE PRESENTATION: A 56-year-old, non-smoking, previously healthy woman presented with a four week history of exertional progressive dyspnea. Evaluation by an outside hospital showed bilateral alveolar consolidations on chest radiography with leukocytosis prompting admission for presumptive pneumonia. Due to persistence of symptoms and alveolar consolidations despite intravenous antibiotic therapy, she was referred to our institution. Examination revealed pulse oxymetry of 88% correcting to 96% with supplemental oxygen. There were inspiratory crackles with coarse breath sounds at both lung bases. Her joints were normal. Laboratory data showed leukocytosis with neutrophil predominant left shift, erythrocyte sedimentation rate of 53 mm/h (Westergren), and anti-CCP greater than 250 U/mL. Her rheumatoid factor (RF) was normal. A chest radiography and computed tomography (CT) (figure 1) revealed patchy alveolar opacities in both lungs. A diagnostic bronchoscopy with broncho-alveolar lavage (BAL) showed a total white cell count of 4.82 x 105 mL-1 with 54% lymphocytes, 20% eosinophils, 10% plasma cells, 7% basophils, 7% neutrophils and 2% macrophages. The CD4 to CD8 ratio was 0.6. She underwent a diagnostic video-assisted thoracoscopic surgery wedge biopsy of the right lower lobe that revealed organizing pneumonia (OP). She was initiated on 60 mg of prednisone and discharged home with oxygen. Due to gradual resolution of symptoms her prednisone was tapered to 30 mg. Her dyspnea recurred at six months and prednisone was increased back to 60 mg. Repeat chest CT showed resolution of her basal alveolar opacities but presence of fibrosis with traction bronchiectasis. Radiographic imaging of her hands, feet and joints were normal. Her anti-CCP was now greater than 340 U/mL and RF was 222 IU/mL. She is now oxygen dependent, azathioprine was added, and is being evaluated for lung transplantation at our institution.
DISCUSSION: Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) can be the initial manifestation of RA (1). We speculate that she did not develop any joint manifestations due to the high dose steroids initially given. An OP was identified initially by open lung biopsy, which can occur but is less common than usual interstitial pneumonia and non-specific interstitial pneumonia. In addition, anti-CCP preceded appearance of a positive RF.
CONCLUSIONS: In patients who present with organizing pneumonia and anti-CCP, RA should be sought as a possible diagnosis.
1) 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;49(15):1605-1607.
DISCLOSURE: The following authors have nothing to disclose: Carlos Kummerfeldt, Andre Holmes, Ellen Riemer, John Huggins
No Product/Research Disclosure InformationMedical University of South Carolina, Charleston, SC