PULMONARY MANIFESTATIONS OF RHEUMATOID ARTHRITIS
Section snippets
PLEURAL DISEASE
Pleural disease is common in patients with RA. In autopsy series the prevalence of histologic pleural disease is reported between 38% and 73%.75 Involvement of the pleura may be clinically silent or may result in pleurisy or the accumulation of pleural fluid. Pathologic findings in the pleura can vary. Pleural nodules are often seen; biopsy of a pleural nodule may reveal granulation tissue surrounding mononuclear cells palisading around central areas of fibronoid necrosis.81 Nonspecific
RHEUMATOID NODULES
Necrobiotic nodules are a common finding in RA. Subcutaneous nodules occur in 20% of patients seropositive for rheumatoid factor but are rarely seen in patients with seronegative RA.85 These may regress spontaneously or in response to therapy directed at joint or systemic disease. Pathologically, rheumatoid nodules are composed of a central area of fibrinoid necrosis surrounded by palisading mononuclear cells with an outer zone consisting of chronic inflammatory cells and granulation tissue
INTERSTITIAL LUNG DISEASE
Interstitial lung disease (ILD) is the most common pulmonary manifestation of RA. In many cases, disease is clinically silent and is identified by radiographic or physiologic abnormalities or by changes in bronchoalveolar lavage cell profile. Depending on the diagnostic modality used to detect disease, prevalence rates of ILD in RA are reported with wide variance. In general, ILD is seen more frequently in men than women, in the presence of a high rheumatoid factor titer, and in the setting of
Airway Obstruction
Chronic airway obstruction is a common finding in RA.50, 58, 90, 102, 108, 135 In a study by Geddes et al of 100 patients with RA and normal chest radiographs and 84 control subjects matched for age, sex, and smoking habits, indices of air flow obstruction (FEV1, FEV1/FVC, and MMEFR) were significantly lower in the group with RA.50 Overall, the prevalence of air flow obstruction in the RA group was 38%. This study, like other earlier studies, was confounded by the inclusion of large numbers of
Vasculitis
Systemic vasculitis associated with RA usually presents with skin ulcers, mononeuritis multiplex, and digital ischemia. In general, systemic vasculitis in patients with RA is rare. It, however, has been postulated that rheumatoid nodules, a common finding in RA, result from a vasculitic process.42
Primary pulmonary vasculitis is rarely seen in RA. Alveolar hemorrhage and hemoptysis have been described in the setting of a pulmonary renal syndrome.93 Alveolar hemorrhage has also been seen in RA in
DRUG-INDUCED LUNG DISEASE
Several of the medications commonly used to treat RA can be associated with lung injury. A comprehensive review of pulmonary complications of drugs used to treat RA and other connective tissue diseases is presented in the article by Libby and White. A brief overview is provided here.
Infection
Respiratory tract infection is an important source of morbidity in patients with RA. The exact prevalence of pulmonary infection in this population is reported variably. In one study an incidence of bacterial pulmonary infection of 25% was reported.68, 87 The presence of bronchiectasis, airway abnormalities, and parenchymal lung disease may increase the likelihood of infection and the morbidity with which these infections are associated.123 Patients with severe interstitial lung disease, for
CONCLUSION
It should be clear that RA can present in the chest in many different ways. Given the prevalence of RA and the fact that pulmonary complications are frequent, it is likely that practicing clinicians will encounter patients with pulmonary manifestations of RA. In the setting of respiratory symptoms or chest radiographic abnormalities in such patients, an understanding of the types of pleuropulmonary diseases that can be associated with RA should guide diagnostic evaluation and treatment. As some
References (150)
- et al.
Pleural fluid glucose with special reference to its concentration in rheumatoid pleurisy with effusion
Dis Chest
(1960) - et al.
Interstitial pneumonitis complicating rheumatoid arthritis: Sustained remission with azathioprine therapy
Chest
(1977) Interstitial pneumonia and its consequences in rheumatoid disease
British Journal of Diseases of the Chest
(1959)- et al.
Antitrypsin phenotypes in fibrosing alveolitis and rheumatoid arthritis
Lancet
(1977) - et al.
The extra-articular features of rheumatoid arthritis. A systematic analysis of 127 cases
Am J Med
(1973) Poor prognosis in patients with rheumatoid arthritis hospitalized for interstitial lung fibrosis
Chest
(1988)- et al.
A case of Caplan's syndrome in a roof tile worker
Tuberculosis and Lung Disease
(1960) - et al.
Pulmonary manifestations associated with rheumatoid arthritis
Chest
(1991) - et al.
Connective tissue disease and the pleura
Chest
(1993) - et al.
Pulmonary infection in rheumatoid arthritis
Brit J Dis Chest
(1978)
High resolution computed tomography of drug induced lung disease
Clin Radiol
Upper lobe fibrosis and cavitation in rheumatoid disease
British Journal of Diseases of the Chest
Seronegative rheumatoid arthritis
Arthritis Rheum
Risk factors for methotrexate-induced lung injury in patients with rheumatoid arthritis
Ann Intern Med
Successful use of cyclosporine for the treatment of aggressive pulmonary fibrosis in a patient with rheumatoid arthritis
Arthritis Rheum
Pulmonary function of non-smoking patients with rheumatoid arthritis in the presence and absence of secondary Sjögren's syndrome: A Controlled Study
Respiration
Bronchiolitis obliterans associated with rheumatoid arthritis: Findings on HRCT and dynamic expiratory CT
J Comput Assist Tomog
The American Rheumatism Association 1987 Revised Criteria for the Classification of Rheumatoid Arthritis
Arthritis Rheum
Bilateral pneumothoraces and pleural effusions complicating rheumatoid lung disease
Thorax
Rheumatoid arthritis and chronic bronchial suppuration
Scand J Rheumatol
Methotrexate-related pulmonary complications in rheumatoid arthritis
Ann Rheum Dis
Rheumatoid pneumoconiosis: Documentation of onset and pathologic considerations
Am J Med
Rheumatoid arthritis of the cricoarytenoid joint: A clinicopathologic study
Arthritis Rheum
Pulmonary disease associated with rheumatoid arthritis
JAMA
American Review of Respiratory Disease
The treatment of cryptogenic pulmonary fibrosis with immunosuppressant drugs
QJM
Bronchiolitis obliterans organizing pneumonia in patients taking acebutalol or amiodarone
Thorax
Rheumatoid pneumoconiosis in a foundry worker
Thorax
Certain unusual radiologic appearances in the chest of coal miners suffering from rheumatoid arthritis
Thorax
Pleurisy with effusion in rheumatoid arthritis, with reference to the low concentration of glucose in pleural fluid
American Review of Respiratory Disease
Incidence, prevalence, and possible risk factors for pneumonitis in patients with rheumatoid arthritis receiving methotrexate
J Rheumatol
Pulmonary involvement in rheumatoid arthritis
JAMA
Rapidly progressive bronchiolitis obliterans with organizing pneumonia
Am J Respir Crit Care Med
Interrelationship of chronic eosinophilic pneumonia, bronchiolitis obliterans and rheumatoid disease: A hypothesis
J Clin Pathol
Drug-induced pulmonary disease. Part I: Cytotoxic drugs
American Review of Respiratory Disease
A controlled trial of cyclophosphamide in rheumatoid arthritis
N Engl J Med
Use of high resolution computed tomography of the lungs in patients with rheumatoid arthritis
Ann Rheum Dis
Obstructive sleep apnea associated with adult acquired micrognathia from rheumatoid arthritis
American Review of Respiratory Disease
Cryptogenic organizing pneumonitis
QJM
Low-dose methotrexate may cause air trapping in patients with rheumatoid arthritis
Am J Respir Crit Care Med
Immunofluorescent and immunologic studies of rheumatoid lung
Arch Intern Med
Rheumatoid factor accentuation of pulmonary lesions associated with experimental diffuse proliferative lung disease
Arthritis Rheum
Empyema in rheumatoid arthritis
Ann Rheum Dis
Honeycomb lung and chronic rheumatoid arthritis
Ann Rheum Dis
Diffuse interstitial pulmonary fibrosis associated with arthritis
American Review of Respiratory Disease
Pleural effusion in rheumatoid arthritis. Impaired transport of glucose
N Engl J Med
“Rheumatoid Disease” with joint and pulmonary manifestations
Brit Med J
Bronchiolitis obliterans organizing pneumonia
N Engl J Med
Bilateral pneumothoraces and pleural effusions in rheumatoid lung disease
Thorax
Rheumatoid pleural effusion
Arch Pathol
Cited by (128)
Reconstruction of anatomy and care provisioning in a severe case of spondyloepiphyseal dysplasia
2021, International Journal of PaleopathologyBeyond the joints, the extra-articular manifestations in rheumatoid arthritis
2021, Autoimmunity ReviewsRheumatoid Arthritis
2019, Mosaic of Autoimmunity: The Novel Factors of Autoimmune DiseasesBenefits of long-term pilocarpine due to increased muscarinic acetylcholine receptor 3 in salivary glands
2018, Biochemical and Biophysical Research Communications
Address reprint requests to, Lynn T. Tanoue, MD, Section of Pulmonary and Critical Care Medicine, 105 LCI, 333 Cedar Street, New Haven, CT 06520–8057
- *
Duration at least 6 weeks