Interstitial Lung Disease as the Initial Manifestation of Rheumatoid Arthritis: A Case Report and Review of the Literature

Abstract

Background: Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder that primarily affects synovial joints. Approximately 18-41% of patients with RA develop extra-articular manifestations [1]. However, extra-articular manifestations preceding or occurring without articular symptoms in RA have rarely been reported. Such atypical presentations of RA pose a diagnostic challenge to the clinician and may delay treatment. Case presentation: A 57-year-old female with long standing diabetes, hypertension, hyperlipidemia and Raynaud's phenomenon presented shortness of breath, cough and new subcutaneous nodules. Four years before, she had been diagnosed with non specific interstitial pneumonia but had declined treatment. The physical exam did not reveal any signs suggestive of RA however, she was seropositive for rheumatoid factor (RF) and anti-citrullinated peptide antibody (ACPA). Treatment for RA-associated interstitial lung disease was discussed. Conclusion: Extra-articular involvement of RA can be observed as initial presentation of the disease in a handful of cases. However, RA diagnosis must be achieved to correctly manage these patients which can at that time receive targeted therapeutic interventions. From our literature review, pulmonary involvement was seen in over half of the cases in seropositive RA patients who lacked articular involvement at initial presentation.

Slowly Expanding 18F-FDG PET-Positive Irregular Opacities in the Lung Due to Diffuse Lymphoid Hyperplasia Preceding Rheumatoid Arthritis

“…Although Sjögren syndrome is the most common underlying collagen disease of LIP, which is a major component of nonneoplastic LPDs, the diagnostic criteria for Sjögren syndrome were not met in this case 3 . Lung lesions occasionally appear as the initial manifestation of RA, and they are generally OP, which may present as crescentic and ring-shaped opacities, or nonspecific interstitial pneumonia 4,5 . However, to the best of our knowledge, no case of pulmonary LPD, especially DLH, has been reported as the initial manifestation of RA.…”

“…3 Lung lesions occasionally appear as the initial manifestation of RA, and they are generally OP, which may present as crescentic and ring-shaped opacities, or nonspecific interstitial pneumonia. 4,5 However, to the best of our knowledge, no case of pulmonary LPD, especially DLH, has been reported as the initial manifestation of RA. The CT findings of LIP including RA cases have been reported to be characterized by ground-glass opacities, centrilobular nodules, thin-walled cysts, and peribronchovascular thickening.…”

Usefulness of Lung Ultrasound as a Method for Early Diagnosis of Interstitial Lung Disease in Patients with Rheumatoid Arthritis

“…4 Still, it can precede joint symptoms in up to 20% of cases, and respiratory symptoms characterize them it. [5][6][7] Among the pulmonary findings in RA, interstitial lung disease (ILD) stands out. 8 The risk increases with the prolonged duration of RA and active joint RA.…”

Rheumatoid arthritis-associated lung disease in black Africans: Descriptive study of 28 cases in Lomé

“… [6] In some cases, respiratory symptoms may precede the development of joint symptoms or the diagnosis of RA. [7] This may involve all parts of the lung, including pleura, airways, parenchyma and vasculature. [8] These changes may reflect chronic immune activation, increased susceptibility to infection (often related to immunomodulatory medications) or direct toxicity due to disease-modifying or biological therapy.…”