Lung Disease in Rheumatoid Arthritis by Aryeh Fischer & Joyce S. Lee

Author:Aryeh Fischer & Joyce S. Lee
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

Occasionally in RA patients presenting with acute dyspnoea, imaging patterns on HRCT may point to a specific drug, and together with the timing of treatment, a relatively confident diagnosis of drug-related pulmonary toxicity can be made. More often, however, the HRCT findings are those of relatively non-specific ground-glass opacification and consolidation. In this setting, it is important not to overlook the possibility of opportunistic infection, which may have similar HRCT appearances and more likely in RA patients receiving immunosuppressive therapy. A variety of severe infections have been reported with the use of TNFi and rituximab. In one study, the most common infection was bacterial pneumonia which may present on HRCT as focal or multifocal consolidation. In addition to reactivation of tuberculosis (TB), increased susceptibility to nontuberculous mycobacterial infection (NTM) also occurs in RA patients receiving TNFi therapy. NTM infection usually presents on HRCT as a combination of cavitating nodules, tree-in-bud opacification and focal areas of fibrotic scarring causing localized traction bronchiectasis (Fig. 6.16a, b). Numerous fungal infections have also been reported in association with TNFi therapy, including Pneumocystis jirovecii, histoplasmosis, coccidioidomycosis, Cryptococcus and Aspergillus.

Fig. 6.16Nontuberculous mycobacterial infection in two patients being treated with TNFi therapy. (a) Axial HRCT image in a RA patient demonstrating tree-in-bud-type opacities throughout both lungs consistent with exudative bronchiolitis seen in nontuberculous mycobacterial infection. (b) Axial HRCT image in a RA patient with a large cavitation lesion with surrounding demonstrating tree-in-bud-type opacities indicating the presence of exudative bronchiolitis. Nodules with cavitation and tree-in-bud opacification are HRCT features of nontuberculous mycobacterial infection

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