Pulmonary and pleural lesions in rheumatoid disease.

Abstract

Pulmonary and pleural lesions are not uncommon in rheumatoid disease. Nonspecific pleuritis is a frequent finding at necropsy (1, 2), and rheumatoid nodules of the pleura have been observed (3–5). Such nodules have been described in the lungs of coal miners with rheumatoid disease (Caplan's syndrome) (6–8) and in patients with other forms of pneumoconiosis (9–11). In addition, rheumatoid nodules have occasionally been reported in the lungs of patients who had not had such occupational exposures (12–15). In 1943 Ellman and Ball (16) called attention to diffuse pulmonary fibrosis at necropsy in two rheumatoid patients, and subsequently many similar cases were described. The recognition that clinical manifestations may occur with such pulmonary involvement led to the concept of the “rheumatoid lung syndrome.” This concept has not gained universal acceptance largely because of the nonspecificity of some of the pulmonary and pleural changes and the considerable variation in the type of involvement encountered. Thus, Aronoff et at. (17) in 1955 did not note any instances of the “rheumatoid lung syndrome” in their material and emphasized the absence of specific lung lesions. More recently, Talbott and Calkins (18) have taken a similar position, whereas other investigators have concluded that chronic pneumonitis and fibrosis do occur as part of the rheumatoid process (19–25). The purpose of this report is to call attention to the spectrum of pulmonary and pleural changes which may be encountered in this disease and to emphasize certain clinical, radiologic, and pathologic features. Method A review was made of the medical records and radiographs of all patients in our institution with confirmed rheumatoid disease in whom unexplained pulmonary or pleural lesions were demonstrated radiologically during the past fifteen years. In 18 patients these lesions were verified histologically. The nature of the lesions in 17 additional cases remained unexplained in spite of extensive clinical and radiologic evaluation and numerous laboratory tests, but their inclusion in this study was considered justified on the basis of the course of the disease and the combination of certain clinical and radiologic findings. Twenty-one of the 3.5 patients were followed for two years or longer, and several were recalled specifically for additional radiographs, laboratory tests, or further clinical information. It is emphasized that no attempt was made to gauge the prevalence of these lesions in rheumatoid patients, and there may well have been additional cases which did not come to our attention.