Pulmonary Manifestations of Systemic Disease: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I |

Magic, Escapes, and Fraud Exposed: The Houdini Effect FREE TO VIEW

Elizabeth Sonntag, MD; Grant Farr, DO; Rebecca Potfay, MD
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Virginia Commonwealth University, Richmond, VA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1077A. doi:10.1016/j.chest.2016.08.1184
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: We present a case of rheumatoid arthritis diagnosed after an incidental finding of lung mass on abdominal computed tomography (CT).

CASE PRESENTATION: A 74 year old AAM with a 52 pack-year smoking history, hypertension, and coronary artery disease presented to pulmonary clinic for follow up of abnormal imaging. Patient was noted to have incidental finding of a right middle lobe lung mass with central necrosis and mediastinal lymphadenopathy on abdominal CT. Biopsy of mediastinal lymph node was negative for malignancy. Given continued concerns that the mass represented lung cancer, repeat biopsy was planned. Surprisingly, the pre-procedure CT showed significant decrease in mass size (from 4.2 x 2.7cm to 2.3 x 1.7cm) therefore biopsy was aborted. Given the change in size, the area of consolidation was thought to represent infection and repeat imagining was planned to evaluate for resolution. Though follow up CT showed complete resolution of the right middle lobe lesion, it noted new diffuse bilateral lung nodules (ranging in size from 2mm to 14mm). Nodules followed a hematogenous pattern concerning for metastatic disease vs. septic emboli. Infection was ruled out with CBC, blood cultures and TTE. Given the curious nature of the pulmonary findings rheumatologic work-up was initiated, the patient was without rheumatologic complaints and/or physical manifestations of disease. Work-up revealed positive RF (122) and anti-CCP (>250), both are greater than three times the upper limit of normal (specificity >95%)3. The diagnosis of rheumatoid arthritis was made.

DISCUSSION: Pulmonary disease is a common extra-articular manifestation of rheumatoid disease, and is a significant cause of morbidity and mortality.2 The diagnosis, however, is often overlooked in patients with abnormal radiologic findings who are free of systemic or articular disease, even though these findings are known to proceed the articular findings in some cases.1 Risk factors for pulmonary involvement include male gender, smoking history, anti-CCP elevation, and higher titers of RF (all seen in our patient).2 Pulmonary rheumatoid nodules are characterized by a necrotic core on pathology, and unlike malignancies can regress over time. Though, we do not have proven pathology for our patient, the constellation of findings on imaging and laboratory data fit a diagnosis of rheumatoid arthritis.

CONCLUSIONS: Pulmonary complications may precede the typical presentation of rheumatoid disease. Because the diagnosis carries significant morbidity and mortality, rheumatoid disease should be considered in the differential diagnosis of abnormal radiologic pulmonary findings.

Reference #1: Schneider, Frank, MD, et al. “Pleuropulmonary Pathology in Patients With Rheumatic Disease.” Arch Pathol Lab Med Vol.136 (2012).

Reference #2: Massey, H., M. Darby, and A. Edey. “Thoracic Complications of Rheumatoid Disease.” Clinical Radiology 68.3 (2013): 293-301. Web.

DISCLOSURE: The following authors have nothing to disclose: Elizabeth Sonntag, Grant Farr, Rebecca Potfay

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