SESSION TITLE: Interstitial Lung Disease Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: The interstitial compromise in rheumatoid arthritis (RA) is one of the most common forms of both pulmonary and extra-articular involvement. Patterns of usual interstitial pneumonia (UIP) or nonspecific interstitial pneumonia (NSIP) are the most common, and usually indistinguishable from idiopátic forms1. The association between OP (organizing pneumonia) and collagen diseases is known, though rare, and can join or found within another interstitial pneumonia.
CASE PRESENTATION: 43 year old woman with no history of importance. She began with fever, dry cough, dyspnea, fatigue and arthralgia. The chest radiograph showed bilateral opacities. Despite receiving several antibiotic regimens still had fever. Chest CT scan showed subpleural consolidations with air bronchogram in right upper, left upper, middle lobe and lingula. Denies contact with animals, radiotherapy ,QMT or symptoms consistent with rheumatologic disease. Blood, urine and sputum cultures were negative. Laboratory: Ht 34% Hb 11.6 WBC 11 300 (76% Neut, Eo 3%) Creatinine 0.59, Urea 16 LDH 149 Bil T 0.25 D 0.14 ASAT 22 ALAT 23 Erythrosedimentation 132 ,C-reactive protein 11.2. Arterial blood gases: pH 7.42 PCO2 25 PO2 57 37.9 Bic Sat 90%. Bronchoscopy was performed: BAL: Macrophages 81%, Lymphocytes 15%, Neutrophils 3.5%,Eosinophils 0.5%.Negative cultures for AFB, common bacteria and fungi. Transbronchial biopsy: nondiagnostic Videoassisted thoracoscopy: Multiple fibroblastic nodes were observed with endoluminal extension (Masson bodies). The histologic finding support the diagnosis of organizing pneumonia. Rheumatologic profile was requested: CPK 80, Aldolase 4.5, ANA -, Anti DNA -, Anti Ro, Anti citrulinated to AR 226 RF 97.2. At the time of onset of the disease have no symptoms or signs consistent with arthritis. X-Ray from hands and feet without erosions. Treatment with 0.75 mg / kg of meprednisone was began, with marked improvement of the thermal curve and images. Later graduated descent. At the fifth month of treatment with 4 mg meprednisone each day, the patient began with joint pain in hands and feet, Achilles tendinitis and knee pain. Ultrasound was performed: soft hands and feet which shows the presence of synovitis. It confirms the diagnosis of RA.
DISCUSSION: The OP must be distinguished from the COP (cryptogenic organizing pneumonia) 2. The first is associated with infections, radiation and connective tissue diseases. Among these latter, is common to see in the PM-DM (polimyositis dermatomyositis ), and rarely in RA SLE or Sjogren. In RA, in general the articular compromise often precede lung involvement. However, in some cases it may occur otherwise. A high index of suspicion and the presence of altered rheumatologic profile should alert us. Anti antibodies as citrullinated (anti-CCP) or rheumatoid factor (RF) may be positive long time rarely before the disease manifests itself. The Anti-CCP are more specific than rheumatoid factor (S 95% vs 90%) in the diagnosis of RA. These antibodies are detected at early stages of the disease and is associated with a more agresive disease3. In this patient, joint symptoms began to manifest five months after diagnosis of the OP, coinciding with low doses of corticosteroids. The diagnosis of early RA was made according to the criteria of the American College of Rheumatology.
CONCLUSIONS: The diagnosis of OP should exclude infections, and include rheumatic profile with ANA, RF and anti-CCP. This may reveal a diagnosis of an occult collagen vascular disease. While most cases have good response to treatment with corticosteroids, a small percentage of patients with RA and OP have not, and can require cytotoxic drugs.
Reference #1: Kim EJ, Collard HR, King TE Jr. Rheumatoid arthritis-associated interstitial lung disease: The relevance of histopathologic and radiographic pattern. Chest 136: 1397-1405, 2009.
Reference #2: Cordier JF. Cryptogenic organizing pneumonia. Eur Respir J 2006, 28: 422-446.
Reference #3: Whiting PF, et al. Systematic review: accuracy of anti-citrullinated Peptide antibodies for diagnosing rheumatoid arthritis. Ann Intern Med 2010, 152 (7): 456-464.
DISCLOSURE: The following authors have nothing to disclose: Brenda Varela, Edgardo Rhodius, Paula Pucci, Silvana Malnis, Silvia Quadrelli
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