Abstract
BackgroundRheumatoid arthritis has varied pleuroparenchymal manifestations. Wegener's granulomatosis can develop in an established case of rheumatoid arthritis and this association although previously reported is very rare.Case presentationA 60-year-old lady had been diagnosed with rheumatoid arthritis on the basis of her clinical symptoms and serological tests which were positive RA factor and anti-CCP antibodies. Her rheumatoid arthritis activity had been mild and well controlled with hydroxychloroquine and low dose prednisone. She presented with a productive cough and right-sided pleuritic chest pain. CT scan of the chest showed three lung nodules with increased uptake on PET CT scan, raising concerns for an inflammatory or malignant process. The differential diagnosis included rheumatoid nodules, infections or malignancy. A CT-guided needle biopsy of the largest nodule was undertaken which showed vasculitis typical of Wegener's granulomatosis. Stains and cultures of the biopsy specimen were negative for bacteria, fungi and acid fast bacilli. A panel of serological tests for vasculitis were checked and showed elevated titers of cANCA and anti-proteinase 3 antibodies. Urine analysis and CT scan of paranasal sinuses was normal. Since the upper respiratory tract and the kidneys were spared a diagnosis of limited Wegener's granulomatosis affecting only the lungs was made. Due to the toxicity of cyclophosphamide, her relatively mild disease sparing the kidneys and the underlying rheumatoid arthritis, weekly methotrexate was started and low dose prednisone was continued. She had marked symptomatic improvement and complete resolution of the nodules was documented on subsequent imaging.ConclusionWegener's granulomatosis developing in a patient with rheumatoid arthritis is very rare but should be considered as it warrants a different and possibly more aggressive treatment approach.
Highlights
Rheumatoid arthritis (RA) is a systemic inflammatory disorder that has pleuroparenchymal involvement with varied manifestations, which includes organizing pneumonia, interstitial fibrosis, rheumatoid nodules, airway disorders such as bronchiectasis and bronchiolitis and pulmonary vasculitis
We present a rare case of limited Wegener's granulomatosis presenting only as lung nodules in a patient with RA
The presence of RA is confirmed by the erosive arthritis in the joints of her hands and positive RA and anti CCP antibodies at the time of diagnosis
Summary
Rheumatoid arthritis (RA) is a systemic inflammatory disorder that has pleuroparenchymal involvement with varied manifestations, which includes organizing pneumonia, interstitial fibrosis, rheumatoid nodules, airway disorders such as bronchiectasis and bronchiolitis and pulmonary vasculitis. She had RA factor positive rheumatoid arthritis diagnosed about 3 years prior and was doing well with hydroxychloroquine and low dose prednisone Her other medical problems included osteopenia, gastroesophageal reflux disease and hypercholesterolemia for which she was on weekly risedronate, calcium and vitamin D supplements, omeprazole and atorvastatin respectively. Methotrexate was started and the low-dose prednisone was continued Her symptoms improved dramatically with these and a repeat CT scan of the chest obtained one month after treatment showed regression in the size of the nodules and one done 3 months later showed complete resolution of the same. She will be followed closely for development of kidney or upper respiratory tract involvement and monitored for methotrexate toxicity
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