Cavitary nodules in rheumatoid arthritis patients and their prognosis

Abstract

Introduction: Rheumatoid arthritis (RA), which is an autoimmune disease with chronic joint inflammation, is usually associated with pleural parenchymal involvement. Nodules can be seen in lung parenchyma but cavitary properties are rare. Methods: Six patients with necrotic cavitary pulmonary nodules are included. Clinical features, treatment and imaging details were presented. Results: All patients (n=6) with necrotic cavitary nodules were seropositive. All patients received leflunomide as conventional disease modifying anti-rheumatic drug (DMARD), while etanercept (n=1), infliximab (n=1), rituximab (n=1) and abatacept (n=3) as biological DMARD treatment. Except for one case (Case 2), all patients underwent bronchoscopy and nothing isolated from microbiological cultures. In the only biopsied case, the pathology was interpreted as a necrotizing rheumatoid nodule. In four patients, nodules were interpreted as in favor of the rheumatoid nodule. Mild-to-moderate FDG uptake was observed in five patients with PET-CT. In one patient (Case 6) without pulmonary nodules with methotrexate, new pulmonary nodules were developed, showed cavitation and progression after the transition to leflunomide. In another patient (Case 4), nodules developed under leflunomide were observed to cavitate after abatacept. In a patient (Case 1) receiving certolizumab, treatment was discontinued after nodules gain cavitary properties but even after those nodules tended to progress in size. Conclusion: It should be kept in mind that cavitary pulmonary nodules in patients with RA can be associated with the disease itself or with the conventional (especially leflunomide) or biological DMARD therapies.