Thoracic lung involvement in rheumatoid arthritis: Findings on HRCT Poster No.: C-2488 Congress: ECR 2015 Type: Educational Exhibit Authors: R. E. Correa Soto, M. J. Martín Sánchez, J. M. Fernandez 1 1 2 3 1 1 2 4 Garcia-Hierro, D. Palominos Pose, K. müller campos, A. Casas Martín ; SALAMANCA/ES, Carbajosa de la Sagrada/ES, 3 4 Barcelona/ES, Santiago/CL Keywords: Image compression, Education, CT-High Resolution, Respiratory system, Lung, Thorax, Arthritides DOI: 10.1594/ecr2015/C-2488 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 16
Learning objectives To review the pathology and symptoms/signs of lung involvement in rheumatoid arthritis (RA). Describe and explain the findings of pulmonary involvement of RA in highresolution computed tomography (HRCT). Understand and describe the radiological differential diagnosis. Background RA is a chronic multisystem disease of unknown etiology with a prevalence of 1-2% of the general population. It occurs more often in women than in men, with the highest incidence occuring between the ages of 25 and 50 years. In nearly 50% of patients with rheumatoid arthritis, there is some form of extraarticular involvement in the disease process. Lung disease is the second most common cause of death, after infection. Although the characteristic alteration is an inflammatory sinovitis with production of a chronic polyarthritis, extra-articular manifestations appear frequently, being more common in men. There are rheumatoid nodules, muscle atrophy, rheumatoid vasculitis, pleuropulmonary manifestations and pericarditis. Pulmonary symptoms occur months or years after the onset of the joint disease. Clinical signs of pulmonary involvement can include dyspnea, cough, pleuritic pain, finger clubbing, hemoptysis, infection, bronchopleural fistula or pneumothorax. Patients may also be asymptomatic. Findings and procedure details From July 2009 to July 2014, we reviewed the patients diagnosed in our hospital, of pleuropulmonary involvement in the context of RA, more representatives to describe this entity. In RA patients the HRCT is abnormal in 50%, being more sensitive than pulmonary function tests. Page 2 of 16
The most common abnormality in RA is the pleural disease with pleural effusion or pleural thickening. The pleural effusion is much more common in men. In general it is small to large, usually unilateral and transient, persistent, or relapsing. As a complication, the pleural effusion can infect and transform into an empyema. Rheumatoid lung disease: The patterns of interstitial disease are diverse and include nonspecific interstitial pneumonia (NSIP), usual interstitial pneumonia (UIP), cryptogenic organizing pneumonia and folicular bronchiolitis. The most common pattern is UIP. Chest radiographic: honeycomb cysts most evident at the lung bases and peripheral reticular opacities with lower-lobe volumen loss. Computed tomography: the abnormalities have a distribution basal and peripheral. There are reticular opacities, honeycomb cysts, traction bronchiectasis and bronchiolectasis. When the disease is advanced, there are architectural distortion and lobar volumen loss. Rheumatoid pulmonary nodules occur more often in men with positive rheumatoid factor, smoking and subcutaneous nodules. Pulmonary nodules may arise before rheumatoid arthritis is manifested clinically or may develop concurently. They typically have a máximum diameter of 0.5-7.0 cm, are usually located in peripheral zones of the upper and middle lung regions, and are commonly asymptomatic. Pulmonary nodules may undergo cavitation, increase in size, or resolve spontaneously over time, and new ones may arise as older ones resolve. These can associated with pleural effusion, pneumothorax or hydropneumothorax. Respiratory disease: Obliterative bronchiolitis is also a complication of rheumatoid arthritis. In CT there are mosaic attenuation pattern with scattered areas of air trapping on expiratory CT images. Associated bronchiectasis and bronchial wall thickening also is often seen. In some cases follicular bronchiolitis is also seen. HRCT findings include multiple micronodules, which often show ground-glass attenuation, in a predominantly centrilobular distribution. Page 3 of 16
Drug reaction Various drugs used to treat rheumatoid arthritis may cause lung disease. It can appear infiltrative lung disease, opportunistic infections, hypersensitivity pneumonitis and diffuse alveolar damage. Some of the drugs are: gold salts, penicillamine and methotrexate. The CT reveals patchy ground-glass opacities with centrilobular nodules and lymphadenopathy. Discontinuation of drug therapy and initiation of high dose corticosteroid therapy usually lead to a good outcome. In the differential diagnoses are: 1. 2. 3. 4. Idiophatic pulmonary fibrosis: Pulmonary involvement is peripheral with basilar fibrosis and honeycombing on HRCT. Absence of pleural, pericardial and airways disease, as well as skeletal erosions. Scleroderma: There are identical imaging findings with NSIP pattern on HRCT. This disease is characterized by dilation of the esophagus, because relaxation of lower esophageal sphincter. Hallmark is acroosteolysis. Cryptogenic organizing pneumonia: May exhibit identical imaging findings with UIP pattern on HRCT. There are pleural plaques with calcification or thickening. For diagnosis is key occupational history and there isn t skeletal erosions. Asbestosis: Pulmonary involvement is bilateral or unilateral with patchy consolidations or ground-glass opacities. It is often subpleural or peribronchial. Basilar irregular linear opacities are also seen. Images for this section: Page 4 of 16
Fig. 1: Right and left pleural effusion. Page 5 of 16
Fig. 2: Axial HRCT of a patient with RA shows pulmonary fibrosis with honeycombing (red arrow), reticulation, and mild ground-glass opacity, suggestive of usual interstitial pneumonia pattern of disease. Page 6 of 16
Fig. 3: Axial expiratory HRCT of a patient with RA shows large regions of air-trapping (red arrow) secondary to RA-related constrictive bronchiolitis. Traction bronchiectasis (yellow arrow), reticulation, and mild ground-glass opacity, suggestive of usual interstitial pneumonia pattern of disease. Page 7 of 16
Fig. 4: Axial expiratory HRCT of a patient with RA shows a nodule (red arrow), consistent with a rheumatoid nodule. Page 8 of 16
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Fig. 5: Axial expiratory HRCT of a patient with RA shows large regions of air-trapping secondary to RA-related constrictive bronchiolitis. Traction bronchiectasis, reticulation, and mild ground-glass opacity, suggestive of usual interstitial pneumonia pattern of disease. Page 10 of 16
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Fig. 6: Axial HRCT of a patient with RA shows pulmonary fibrosis with honeycombing (red arrow), reticulation, and mild ground-glass opacity, suggestive of usual interstitial pneumonia pattern of disease. Page 12 of 16
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Fig. 7: HRCT coronal of a patient with RA. Solid subpleural nodule, 15 mm of diameter, in the anterior segment of the left upper lobe, consisting of a rheumatoid nodule. Fig. 8: HRCT sagittal of a patient with RA. Solid subpleural nodule, 15 mm of diameter, in the anterior segment of the left upper lobe, consisting of a rheumatoid nodule. Page 14 of 16
Conclusion The lung is a relatively frequent site of extraarticular involvement in RA. HRCT detected lung disease even in the absence of respiratory symptoms and lung function test positive. The most common finding is the pleural effusion or thickening, followed by interstitial fibrosis, interstitial pneumonia and nodules. The most usual airway involvement are bronchiectasis and air trapping. Differential diagnosis are idiophatic pulmonary fibrosis, scleroderma, cryptogenic organizing pneumonia and asbestosis. Personal information References Lynch DA: Lung disease related to collagen vascular disease. J Thorac Imaging. 24(4):299-309, 2009. Lee HK et al: Histopathologic pattern and clinical features of rheumatoid arthritis-associated interstitial lung disease. Chest. 127(6):2019-27, 2005. Lynch DA et al: Idiopathic interstitial pneumonias: CT features. Radiology. 236(1):10-21, 2005. Zrour SH et al: Correlations between high-resolution computed tomography of the chest and clinical function in patients with rheumatoid arthritis. Prospective study in 75 patients. Joint Bone Spine. 72(1):41-7, 2005. Biederer J et al: Correlation between HRCT findings, pulmonary function tests and bronchoalveolar lavage cytology in interstitial lung disease associated with rheumatoid arthritis. Eur Radiol. 14(2):272-80, 2004. Fischer T et al. The idiopathic interstitial pneumonias: a beginner's guide. Imaging. 16, 37-49, 2004. Tanaka N et al: Collagen vascular disease-related lung disease: highresolution computed tomography findings based on the pathologic classification. J Comput Assist Tomogr. 28(3):351-60, 2004. Terasaki H et al: Respiratory symptoms in rheumatoid arthritis: relation between high resolution CT findings and functional impairment. Radiat Med. 22(3):179-85, 2004. Page 15 of 16
Yoshinouchi T et al: Nonspecific interstitial pneumonia pattern as pulmonary involvement of rheumatoid arthritis. Rheumatol Int. 2004. Dawson JK et al: Predictors of progression of HRCT diagnosed fibrosing alveolitis in patients with rheumatoid arthritis. Ann Rheum Dis. 61(6):517-21, 2002. Dawson JK et al: Fibrosing alveolitis in patients with rheumatoid arthritis as assessed by high resolution computed tomography, chest radiography, and pulmonary function tests. Thorax. 56(8):622-7, 2001. Flaherty KR et al: Histopathologic variability in usual and nonspecific interstitial pneumonias. Am J Respir Crit Care Med. 164(9):1722-7, 2001. Rockall AG et al: Imaging of the pulmonary manifestations of systemic disease. Postgrad Med J. 77(912):621-38, 2001. Demir R et al: High resolution computed tomography of the lungs in patients with rheumatoid arthritis. Rheumatol Int. 19(1-2):19-22, 1999. Perez T et al: Airways involvement in rheumatoid arthritis: clinical, functional, and HRCT findings. Am J Respir Crit Care Med. 157(5 Pt 1):1658-65, 1998 Page 16 of 16