PULMONARY INVOLVEMENT IN COMMON RHEUMATOLOGIC DISEASES IN THE ELDERLY

Abstract

The combination of an older patient, rheumatic disease, and pulmonary lesions can be an important clue to clinical diagnosis and have a major impact on treatment decisions. Although most rheumatic diseases can occur in the elderly, age can have an important effect on the incidence and clinical manifestations of the disease. For example, certain diseases almost never begin in the elderly: Still's disease, Kawasaki disease, and rheumatic fever are virtually unheard of in that population. Other rheumatic diseases, such as the spondyloarthropathies and systemic lupus erythematosus (SLE), uncommonly present in the elderly, although their consequences may persist into old age. On the other hand, some diseases are far more likely to present after 60 years of age, and some almost exclusively so: these include osteoarthritis, calcium pyrophosphate dihydrate deposition disease (pseudogout), polymyalgia rheumatica, and temporal arteritis/giant cell arteritis. Some diseases can begin at any phase of adult life, but their presentations may differ in the young and old: SLE and rheumatoid arthritis (RA) fit this category. This variability may be due in part to the presence of comorbid conditions, which can mimic, accentuate, or ameliorate some of the manifestations of the underlying rheumatic disease. Finally, end-organ damage sustained at a young age may become clinically manifest or significant only when the patient is older. For example, the inflammation and destruction of the joints in RA likely occurs in the early phases of the disease, but the severe deformity that results may become apparent only when the patient is older and the inflammation has burned out. Many of the rheumatic diseases seen in the elderly do not affect the lung, including osteoarthritis, gout, and pseudogout. On the other hand, the lung is a common target organ for a number of rheumatic diseases (Table 1). It can be difficult to use these relationships in the differential diagnosis of rheumatic disease, however, because the lung can respond to injury in only a limited number of ways. Many of the rheumatic diseases can cause pulmonary fibrosis or pleural effusions; several can cause pneumonitis, pulmonary hypertension, and bronchiolitis obliterans. Finally, a number of the drugs used to treat rheumatic diseases can themselves cause lung toxicity, which can be difficult to distinguish from that of the underlying illness. In this article we briefly review the common rheumatic diseases that can occur in the elderly and that can have clinically significant lung involvement.