RARE PRESENTATION OF LUNG DISEASE IN RHEUMATOID ARTHRITIS

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Rheumatoid Arthritis (RA) is a common and functionally disabling disease. Over 2 million adults in the United States have RA. Pulmonary complications are common and responsible for 10 to 20% of all mortality. Rheumatoid nodules are the most common pulmonary manifestations of RA and are usually asymptomatic. In rare cases, they progress to cavitary formation and cause severe clinical symptoms. The following case documents a patient with RA who was found to have cavitary lesions in the lungs. CASE PRESENTATION: 59-year-old male with history of RA (diagnosed in 2014) came to the pulmonologist office for follow up. Patient currently takes Methotrexate and Leflunomide but was off these medications due to insurance issues. Patient was having a dry cough, but no other pulmonary symptoms such as hemoptysis or pleuritic chest pain. Patient denied fever, chills, night sweats or weight loss. A review of his labs showed positive ANA, dsDNA, antihistone, rheumatoid factor, anti-CCP antibodies, along with elevated ESR and CRP. ANCA- myeloperoxidase and proteinase 3, as well as TB Quantiferon testing was negative. Patient's most recent pulmonary function tests failed to show any air flow limitation. Patient had a CT chest in May 2018, which showed multiple sub-centimeter pulmonary nodules with some of them having cavitation (Figure 1). A follow up CT chest was done in Feb 2019 which showed interval increase in size and degree of cavitation in the pulmonary nodules (Figure 2). There is no bronchiectasis, ground glass opacities, or honeycombing. Bronchoscopy was done and BAL was negative for viral inclusions and malignant cells. Negative for pneumocystis and other fungi. DISCUSSION: Most patients with RA found to have cavitary pulmonary nodules present with more severe pulmonary findings compared with non-cavitary lesions, and a longer disease duration. Anti-rheumatic drugs, especially Leflunomide, may play a role in the development of this clinical presentation. This patient who was diagnosed with RA was on Leflunomide therapy, however, had a relatively short disease course (5 years) and rapidly progressing cavitary lesions, which is uncommon. CONCLUSIONS: There is insufficient data about cavitary lesions in relatively newly diagnosed RA. There is a need to formulate new studies to gather data on newly diagnosed disease with rapidly progressing lung cavitations. The high frequency of Leflunomide therapy in patients with RA with cavitary pulmonary nodules should also be emphasized. Reference #1: Brown KK. Rheumatoid lung disease. Proc Am Thorac Soc. 2007;4(5):443-8. Reference #2: Kanıtez, N. A., Çelik, S., Öner, S. Y., Ürer, H. N., Bes, C., & Çetinkaya, E. (2017). Cavitary pulmonary nodules in rheumatoid arthritis; case reports and review of the literature. European journal of rheumatology, 5(1), 65-68. DISCLOSURES: No relevant relationships by Upneet Chawla, source=Web Response