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Kim HC, Ji W, Kim MY, Colby TV, Jang SJ, Lee CK, Han SB, Kim DS. Interstitial pneumonia related to undifferentiated connective tissue disease: pathologic pattern and prognosis. Chest 2015; 147:165-172. [PMID: 25211168 DOI: 10.1378/chest.14-0272] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Undifferentiated connective tissue disease (UCTD) involves conditions characterized by both having symptoms of connective tissue disease (CTD) and autoantibodies but not fulfilling the criteria of a specific CTD. The frequency or prognosis of the usual interstitial pneumonia (UIP) pattern in UCTD is unknown, which may be confused with idiopathic pulmonary fibrosis (IPF). This study aimed to investigate the frequency of the UIP pattern in interstitial pneumonia related to UCTD and compare its prognosis with that of IPF and UCTD-nonspecific interstitial pneumonia (UCTD-NSIP). METHODS The medical records of 788 patients presumptively diagnosed with idiopathic interstitial pneumonia at Asan Medical Center from January 2005 to December 2012 were retrospectively reviewed. UCTD was diagnosed according to the criteria by Corte and colleagues, and the prognoses were compared between UCTD-UIP and UCTD-NSIP and between UCTD-UIP and IPF. RESULTS Among 105 patients with UCTD (13.3% of total subjects), 44 had a UIP pattern (by surgical lung biopsy: 24; by high-resolution CT scan: 20), 29 had a nonspecific interstitial pneumonia pattern (by surgical lung biopsy), and nine had an organizing pneumonia pattern (by biopsy). The overall survival of the UCTD-UIP group was shorter than that of the UCTD-NSIP group (P = .021) but significantly better than that of the IPF group (P = .042). CONCLUSIONS A UIP pattern, which seems to be frequent in UCTD, showed a poorer prognosis than that of UCTD-NSIP. However, the prognosis of UCTD-UIP was significantly better than that of IPF, highlighting the importance of searching for underlying UCTD in suspected IPF cases.
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Affiliation(s)
- Ho-Cheol Kim
- Department of Pulmonary and Critical Care Medicine; Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Wonjun Ji
- Department of Pulmonary and Critical Care Medicine; Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Mi Young Kim
- Department of Radiology; Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Thomas V Colby
- Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea; Department of Laboratory Medicine and Pathology; Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Se Jin Jang
- Mayo Clinic, Scottsdale, AZ; Department of Pathology; Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Chang-Keun Lee
- Division of Rheumatology, Department of Internal Medicine; Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Seung Bong Han
- Department of Clinical Epidemiology and Biostatistics; Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea
| | - Dong Soon Kim
- Department of Pulmonary and Critical Care Medicine; Asan Medical Center, College of Medicine, University of Ulsan, Seoul, South Korea.
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302
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Fong WWS, Yoong JKC. Interstitial Lung Disease and Rheumatoid Arthritis: A Review. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/201010581502400106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Interstitial lung diseases (ILDs) are a group of diffuse parenchymal lung disorders that are classified according to different clinical, radiological and histopathological features. Interstitial lung disease can be primary or it can be due to a secondary cause, such as an underlying connective tissue disease (CTD). Rheumatoid arthritis (RA) is the most common CTD, and ILD can be found in a quarter of RA patients. Interstitial lung disease has a significant impact on RA patients in terms of their burden of disease and quality of life. Despite this it remains largely understudied and pathogenesis is unclear. Newer imaging techniques include ultrasound and 18F-FDG PET/CT. Therapeutics that show promise include mycophenolate mofetil and rituximab. Paradoxically, some of the agents that are good in treating articular manifestations in RA patients can result in the worsening or development of ILD.
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Abstract
Rheumatoid arthritis (RA) affects approximately 1% of the US population frequently has extra-articular manifestations. Most compartments of the lung are susceptible to disease. Interstitial lung disease (ILD) and airways disease are the most common forms of RA-related lung disease. RA-ILD carries the worst prognosis and most often manifests in a histologic pattern of usual interstitial pneumonia or nonspecific interstitial pneumonia. There have been no large, well-controlled prospective studies investigating therapies for RA-ILD. Treatment usually entails immunomodulatory agents. Further studies are needed to better understand pathogenic mechanisms of disease that lead to lung involvement in these patients.
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304
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Interstitial lung disease: NHLBI Workshop on the Primary Prevention of Chronic Lung Diseases. Ann Am Thorac Soc 2015; 11 Suppl 3:S169-77. [PMID: 24754826 DOI: 10.1513/annalsats.201312-429ld] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Population-based, longitudinal studies spanning decades linking risk factors in childhood, adolescence and early adulthood to incident clinical interstitial lung disease (ILD) events in late adulthood have not been performed. In addition, no observational or randomized clinical trials have been conducted; therefore, there is presently no evidence to support the notion that reduction of risk factor levels in early life prevents ILD events in adult life. Primary prevention strategies are host-directed interventions designed to modify adverse risk factors (i.e., smoking) with the goal of preventing the development of ILD, whereas primordial prevention for ILD can be defined as the elimination of external risk factors (i.e., environmental pollutants). As no ILD primary prevention studies have been previously conducted, we propose that research studies that promote implementation of primary prevention strategies could, over time, make a subset of ILD preventable. Herein, we provide a number of initial steps required for the future implementation of prevention strategies; this statement discusses the rationale and available evidence that support potential opportunities for primordial and primary prevention, as well as fertile areas for future research of preventive intervention in ILD.
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305
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Rheumatoid arthritis-associated interstitial lung disease: Lung inflammation evaluated with high resolution computed tomography scan is correlated to rheumatoid arthritis disease activity. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.reumae.2014.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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306
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Interstitial Lung Disease of the UIP Variant as the Only Presenting Symptom of Rheumatoid Arthritis. Case Rep Pulmonol 2015; 2015:205175. [PMID: 26137341 PMCID: PMC4475518 DOI: 10.1155/2015/205175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 05/22/2015] [Accepted: 05/26/2015] [Indexed: 11/17/2022] Open
Abstract
Rheumatoid arthritis is a chronic inflammatory disease primarily manifesting with symptoms of joint pain. It also involves multiple organ systems in the body, including the lungs. Interstitial lung disease (ILD) is the most common form of pulmonary involvement in rheumatoid arthritis (RA). Without the typical symptoms such as chronic joint pain, establishing the diagnosis of RA could be quite challenging and a high index of suspicion is thereby required to diagnose ILD in patients with RA, thereby delaying treatment and increasing morbidity and mortality. We report a case of a 67-year-old Hispanic male with no previous history of rheumatoid arthritis or symptoms of typical joint pain who comes to the hospital only with the chief complaints of progressive worsening of shortness of breath for a duration of 6 months and was eventually diagnosed with ILD of the usual interstitial pneumonia variant with serologies positive for rheumatoid arthritis.
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307
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Ruano CA, Lucas RN, Leal CI, Lourenço J, Pinheiro S, Fernandes O, Figueiredo L. Thoracic Manifestations of Connective Tissue Diseases. Curr Probl Diagn Radiol 2015; 44:47-59. [DOI: 10.1067/j.cpradiol.2014.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 06/27/2014] [Accepted: 07/13/2014] [Indexed: 01/15/2023]
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Papanikolaou IC, Boki KA, Giamarellos-Bourboulis EJ, Kotsaki A, Kagouridis K, Karagiannidis N, Polychronopoulos VS. Innate immunity alterations in idiopathic interstitial pneumonias and rheumatoid arthritis-associated interstitial lung diseases. Immunol Lett 2014; 163:179-86. [PMID: 25540922 DOI: 10.1016/j.imlet.2014.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 12/01/2014] [Accepted: 12/03/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND This is a prospective cohort study elucidating innate immunity in idiopathic pulmonary fibrosis (IPF), cryptogenic organizing pneumonia (COP), rheumatoid arthritis-associated usual interstitial pneumonia (RA-UIP) and RA-associated non specific interstitial pneumonia (RA-NSIP). METHODS 23 IPF subjects, 9 COP subjects, 5 RA-UIP subjects, 8 RA-NSIP subjects were enrolled. 10 subjects were excluded. 19 healthy subjects served as controls. Blood and bronchoalveolar lavage (BAL) were obtained. Natural killer (NK) and NKT cells, NK cells apoptosis and the expression of triggering receptor expressed on myeloid cells type 1 (TREM-1) were assessed. Tumor necrosis factor-α (TNF-α) production was measured in cell cultures after stimulation with lipopolysaccharide endotoxin (LPS) and Pam3CysSK3, and in BAL. Surface expression of Toll-like receptors (TLR) 2 and 4 on peripheral blood monocytes (PBMC's) and circulating NK cells was also assessed. RESULTS RA-NSIP had low blood NKs, marginally insignificant (p=0.07). These NKs poorly produced TNF-α after LPS stimulation. TLR's expression on NK cells was similar throughout disease groups and controls. PBMC's mainly from IPF patients exhibited low TNF-α production after LPS stimulation but not after Pam3CysSK3 stimulation, while TLR4 expression on PBMC's was found normal in all study groups. TLR2 expression on PBMC's was increased in IPF, but mainly in COP, RA-UIP and RA-NSIP (p=0.015). TREM-1 expression was significant on COP monocytes and on COP neutrophils versus controls. RA-NSIP monocytes also exhibited TREM-1 expression (p=0.07). Decreased TNF-α concentration in BAL was finally observed in IPF and RA-UIP. CONCLUSIONS Innate immunity in the lungs and the peripheral circulation in IPF and RA-UIP are similar and more fibrotic than in RA-NSIP which is characterized by NK cell depletion and dysfunction. TREM-1 and TLR's likely affect patterns of inflammation in various interstitial lung diseases.
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Affiliation(s)
- Ilias C Papanikolaou
- 3rd Pulmonary Department, Sismanoglion General Hospital, Sismanogliou 1, 15126 Attica, Greece.
| | - Kyriaki A Boki
- Rheumatology Department, Sismanoglion General Hospital, Sismanogliou 1, 15126 Attica, Greece.
| | | | - Antigoni Kotsaki
- 4th Department of Internal Medicine, ATTIKON University General Hospital, Rimini 1, 12462 Attica, Greece.
| | - Konstantinos Kagouridis
- 3rd Pulmonary Department, Sismanoglion General Hospital, Sismanogliou 1, 15126 Attica, Greece.
| | - Napoleon Karagiannidis
- 3rd Pulmonary Department, Sismanoglion General Hospital, Sismanogliou 1, 15126 Attica, Greece.
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309
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Moua T, Zamora Martinez AC, Baqir M, Vassallo R, Limper AH, Ryu JH. Predictors of diagnosis and survival in idiopathic pulmonary fibrosis and connective tissue disease-related usual interstitial pneumonia. Respir Res 2014; 15:154. [PMID: 25472884 PMCID: PMC4264556 DOI: 10.1186/s12931-014-0154-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 11/20/2014] [Indexed: 01/22/2023] Open
Abstract
Background Although usual interstitial pneumonia (UIP) appears to portend better survival when associated with connective tissue disease (CTD-UIP), little is known about the presenting clinical, radiologic, and pathologic features that differentiate pathologically confirmed UIP with CTD from idiopathic pulmonary fibrosis (IPF). In patients with atypical radiologic and clinical features, what specific findings predict underlying IPF vs. CTD-UIP diagnosis and their respective long term survival? Methods A large retrospective cohort analysis was done of consecutive patients seen from 1995 through 2010 with biopsy confirmed UIP completed or reviewed at our institution. CTD-UIP was defined by independent rheumatology consultation with exclusion of all other secondary causes of lung fibrosis. Primary clinical data was collected and compared for IPF and CTD-UIP along with logistic regression performed for predictors of disease likelihood and Cox proportional hazards analysis for predictors of survival. Results Six hundred and twenty five patients were included in the study of which 89 had diagnosed CTD-UIP representing 7 disease entities. Survival was better among those with CTD-UIP except in UIP associated with rheumatoid arthritis, which had similar presenting features and survival to IPF. Predictors of underlying CTD included female gender, younger age, positive autoimmune serology, and inconsistent presenting radiologic findings. Only age and forced vital capacity corrected for a priori covariates were predictive of survival in CTD-UIP. Conclusions UIP pathology occurs frequently among patients with atypically presenting clinical and radiologic features, and may represent IPF or CTD-UIP with improved prognosis if underlying CTD is diagnosed. Presenting radiologic and pathologic features alone are not predictive of underlying secondary cause or survival between the two groups.
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Affiliation(s)
- Teng Moua
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55901, USA.
| | - Ana C Zamora Martinez
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55901, USA.
| | - Misbah Baqir
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55901, USA.
| | - Robert Vassallo
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55901, USA.
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55901, USA.
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55901, USA.
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310
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Comarmond C, Crestani B, Tazi A, Hervier B, Adam-Marchand S, Nunes H, Cohen-Aubart F, Wislez M, Cadranel J, Housset B, Lloret-Linares C, Sève P, Pagnoux C, Abad S, Camuset J, Bienvenu B, Duruisseaux M, Hachulla E, Arlet JB, Hamidou M, Mahr A, Resche-Rigon M, Brun AL, Grenier P, Cacoub P, Saadoun D. Pulmonary fibrosis in antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis: a series of 49 patients and review of the literature. Medicine (Baltimore) 2014; 93:340-349. [PMID: 25500703 PMCID: PMC4602438 DOI: 10.1097/md.0000000000000217] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Pulmonary fibrosis (PF) is an uncommon manifestation observed in patients with antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV), particularly microscopic polyangiitis (MPA). While patients with PF associated with AAV seem to have a worse prognosis, these patients have been described only in case reports or small retrospective case series. In this retrospective multicenter study, we report the main features and long-term outcomes of patients with PF associated with AAV, fulfilling the American College of Rheumatology criteria and/or Chapel Hill definitions. Forty-nine patients (30 men [61%]; median age at diagnosis of AAV, 68 [interquartile range, 58-73] years) with PF associated with AAV were identified. Forty (81.6%) patients had MPA and 9 (18.4%) had granulomatosis with polyangiitis. The diagnosis of PF preceded the onset of vasculitis in 22 (45%) patients. Usual interstitial pneumonia was the main radiologic pattern (n = 18, 43%). ANCA were mostly of antimyeloperoxidase specificity (88%). All patients were treated with glucocorticoids as induction therapy, combined with cyclophosphamide (CYC) (n = 36, 73.5%) or rituximab (RTX) (n = 1, 2%). Factors associated with mortality included occurrence of chronic respiratory insufficiency (hazard ratio [HR], 7.44; 95% confidence interval [CI], 1.6-34.5; p = 0.003), induction therapy with glucocorticoids alone (HR, 2.94; CI, 1.05-8.33; p = 0.04), and initial weigh loss (HR, 2.83; CI, 1.05-7.65; p = 0.041). The 3-year survival rate in patients treated with glucocorticoids alone or combined with an immunosuppressant (CYC or RTX) as induction therapy was 64% (95% CI, 41-99) and 94% (95% CI, 86-100), respectively (p = 0.03). After a median follow-up of 48 months [interquartile range, 14-88 mo], 18 (37%) patients died, including 11 related to respiratory insufficiency. PF is a rare manifestation of AAV with a very poor prognosis. Induction therapy with CYC might improve the outcome.
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Affiliation(s)
- Cloé Comarmond
- From the Departement Hospitalo-Universitaire I2B (CC, B. Hervier, PC, DS), UPMC Univ Paris 06, UMR 7211, F-75005, Paris; INSERM, UMR_S 959 (CC, PC, DS), F-75013, Paris; CNRS, UMR 7211 (CC, PC, DS), F-75005, Paris; AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology (CC, B. Hervier, FCA, PC, DS), F-75013, Paris; AP-HP, Hôpital Bichat, Service de Pneumologie A (BC), Université Paris Diderot-Paris VII, Paris; AP-HP, Hôpital Saint-Louis, Service de Pneumologie (AT), Université Paris Diderot-Paris VII, Sorbonne Paris Cité, INSERM UMR 717, Paris; Centre Hospitalier Régional et Universitaire de Tours, Service de Pneumologie (SAM), Tours; AP-HP, Centre Hospitalier et Universitaire d'Avicenne, Service de Pneumologie (HN), Bobigny; AP-HP, Hôpital Tenon, Service de Pneumologie (MW, J. Cadranel), UPMC-Paris VI, Paris; Centre Hospitalier Intercommunal de Créteil, Service de Pneumologie (B. Housset), Créteil; AP-HP, Hôpital Lariboisière, Service de Médecine Interne A (CLL), Paris; Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service de Médecine Interne (PS), Lyon; AP-HP, Centre hospitalier et universitaire d'Avicenne, Service de Médecine Interne (SA), Bobigny; Centre Hospitalier Victor Dupouy, Service de Pneumologie (J. Camuset), Argenteuil; Centre Hospitalier et Universitaire de Caen, Service de Médecine Interne (BB), Caen; Centre Hospitalier Universitaire de Grenoble, Service de Pneumologie, Pôle Thorax et Vaisseaux (MD), Grenoble; Hôpital Claude Huriez, Service de Médecine Interne (EH), Université Lille Nord-de-France, Lille; AP-HP, Hôpital Européen Georges Pompidou, Service de Médecine Interne (JBA), Paris; Centre Hospitalier Universitaire de Nantes, Hôtel-Dieu, Service de Médecine Interne (MH), Nantes; AP-HP, Hôpital Saint-Louis, Service de Médecine Interne (AM), Université Paris Diderot-Paris VII, Paris; AP-HP, Hôpital Saint-Louis, Service de Biostatistiques (MRR), Université Paris Diderot-Paris VII, Paris; AP-HP, Groupe Hospitalier Pitié-Salpétrière, Service de Radiologie (ALB, PG), UPMC-Paris VI, Paris, France; and Mount Sinai Hospital, Division of Rheumatology (CP), University of Toronto, Toronto, Ontario, Canada
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Winstone TA, Assayag D, Wilcox PG, Dunne JV, Hague CJ, Leipsic J, Collard HR, Ryerson CJ. Predictors of mortality and progression in scleroderma-associated interstitial lung disease: a systematic review. Chest 2014; 146:422-436. [PMID: 24576924 DOI: 10.1378/chest.13-2626] [Citation(s) in RCA: 170] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Interstitial lung disease (ILD) is the leading cause of morbidity and mortality in patients with systemic sclerosis (SSc); however, prognostication of SSc-associated ILD (SSc-ILD) remains challenging. We conducted a systematic review to identify variables that predict mortality and ILD progression in SSc-ILD. METHODS Three databases were searched to identify all studies relating to predictors of mortality or ILD progression in SSc-ILD. Studies were eligible if they were published in English and included ≥ 10 adults with SSc-ILD. Two authors independently reviewed and extracted data from acceptable studies. RESULTS The initial search identified 3,145 unique citations. Twenty-seven studies, including six abstracts, met the inclusion criteria. A total of 1,616 patients with SSc-ILD were included. Patient-specific, ILD-specific, and SSc-specific variables predicted mortality and progression; however, most predictors were identified in only one study. Most studies did not fully account for potential confounders, and none of the studies included a validation cohort. Older age, lower FVC, and lower diffusing capacity of carbon monoxide predicted mortality in more than one study. Male sex, extent of disease on high-resolution CT (HRCT) scan, presence of honeycombing, elevated KL-6 values, and increased alveolar epithelial permeability were identified as predictors of both mortality and ILD progression on unadjusted analysis. The extent of disease on HRCT scan was the only variable that independently predicted both mortality and ILD progression. CONCLUSIONS Mortality and ILD progression were predicted by several patient-specific, ILD-specific, and SSc-specific factors. Additional prospective studies are required to validate these preliminary findings and to identify combinations of variables that accurately predict the prognosis of SSc-ILD.
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Affiliation(s)
- Tiffany A Winstone
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Deborah Assayag
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Pearce G Wilcox
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - James V Dunne
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Cameron J Hague
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Harold R Collard
- Department of Medicine, University of California San Francisco, San Francisco, CA
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312
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A comparative study of honeycombing on high resolution computed tomography with histologic lung remodeling in explants with usual interstitial pneumonia. Pathol Res Pract 2014; 211:55-61. [PMID: 25433993 DOI: 10.1016/j.prp.2014.08.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 08/09/2014] [Accepted: 08/18/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is little information comparing high-resolution computed tomography (HRCT) findings in UIP with different components that make up remodeling histologically. DESIGN We compared histologic features with HRCT scans from 69 explants with UIP. The extent of 7 histologic features were semi-quantitated: respiratory-lined cysts, bronchiolectasis, pulmonary interstitial emphysema (PIE), lobular remodeling, areas resembling non-specific interstitial pneumonia (NSIP), desquamative interstitial pneumonia (DIP)-like pattern, and mucus pooling within cysts extending into surrounding parenchyma. Subpleural cystic spaces and areas of lobular remodeling were measured morphometrically. Histologic features were compared to three findings on HRCT: diagnostic pattern (UIP, probable UIP, or inconsistent with UIP pattern), degree of honeycombing, and degree of ground-glass opacities. RESULTS Histologically, respiratory-lined cysts were observed in 78%, bronchiolectasis in 83%, interstitial emphysema in 22%, lobular remodeling in 96%, NSIP-like areas in 87%, DIP-like reaction in 10%, and mucin extravasation in 78%. Morphometrically, cysts of PIE measured 6.2±2.9 mm, respiratory-lined cysts 3.5±2.4 mm, and bronchiolectatic cysts 3.3±1.5 mm. Remodeled lobules measured 3.6±1.1 mm. UIP pattern on CT correlated strongly with histologic extent of bronchiolectasis (p=0.001). HRCT honeycombing showed a positive correlation with histologic bronchiolectasis (p=0.001) and respiratory-lined cysts (p=0.001). GGO was positively associated with NSIP-like areas (p=0.02) and extravasated mucus (p=0.05). CONCLUSIONS HRCT findings typical of UIP and HRCT honeycombing correlate best with bronchiolectasis histologically. NSIP pattern is common, and is associated with CT finding of GGO.
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313
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Abstract
Pulmonary complications are an important extra-articular feature of autoimmune rheumatic diseases and a major cause of mortality. The underlying pathogenesis probably involves multiple cellular compartments, including the epithelium, lung fibroblasts, and the innate and adaptive immune system. Heterogeneity in the extent and progression of lung fibrosis probably reflects differences in underlying pathogenic mechanisms. Growing understanding of the key pathogenic drivers of lung fibrosis might lead to the development of more effective targeted therapies to replicate the treatment advances in other aspects of these diseases. Interstitial lung disease (ILD) in connective tissue disease (CTD) is characterized using the classification of the idiopathic interstitial pneumonias. Systemic sclerosis is most frequently associated with ILD and, in most of these patients, ILD manifests as a histological pattern of nonspecific interstitial pneumonia. Conversely, in rheumatoid arthritis, the pattern of ILD is most often usual interstitial pneumonia. The key goals of clinical assessment of patients with both ILD and CTD are the detection of ILD and prognostic evaluation to determine which patients should be treated. Data from treatment trials in systemic sclerosis support the use of immunosuppressive therapy, with the treatment benefit largely relating to the prevention of progression of lung disease.
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314
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Doyle TJ, Dellaripa PF, Batra K, Frits ML, Iannaccone CK, Hatabu H, Nishino M, Weinblatt ME, Ascherman DP, Washko GR, Hunninghake GM, Choi AMK, Shadick NA, Rosas IO. Functional impact of a spectrum of interstitial lung abnormalities in rheumatoid arthritis. Chest 2014; 146:41-50. [PMID: 24305643 DOI: 10.1378/chest.13-1394] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Approximately 10% of patients with rheumatoid arthritis (RA) have interstitial lung disease (ILD), and one-third have subclinical ILD on chest CT scan. In this study, we aimed to further characterize functional decrements in a spectrum of RA-associated ILD. METHODS All subjects were enrolled in the Brigham and Women's Hospital Rheumatoid Arthritis Sequential Study (BRASS). The presence of interstitial lung abnormalities (ILAs) on clinically indicated chest CT scans was determined using a previously validated sequential reading method. Univariate and multivariate analyses were used to assess the association between degree of ILAs and physiologic, functional, and demographic variables of interest. RESULTS Of 1,145 BRASS subjects, 91 subjects (8%) were included in this study. Twelve had radiologically severe ILAs, 34 had ILAs, and 38 had no ILAs on CT scan. Subjects with radiologically severe ILAs were older (P = .0037), had increased respiratory symptoms (cough, P = .027; dyspnea, P = .010), and more severe RA disease (rheumatoid factor, P = .018; total swollen joints, P = .046) compared with subjects with no ILAs. Participants also had a trend toward having an increased smoking history (P = .16) and having lower FVC % predicted (77% vs 94%, P = .097) and diffusion capacity of carbon monoxide % predicted (52% vs 77%, P = .068). Similar but attenuated increases in respiratory symptoms, functional decrements, and RA disease severity were observed in subjects with ILAs compared with those with no ILAs. CONCLUSIONS We have shown that patients with RA have varying degrees of ILAs that are associated with a spectrum of functional and physiologic decrements. Our findings suggest that improved risk stratification and detection of ILAs will provide a therapeutic window that could improve RA-ILD outcomes.
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Affiliation(s)
- Tracy J Doyle
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Paul F Dellaripa
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
| | - Kerri Batra
- Division of Rheumatology, Rhode Island Hospital, Providence RI
| | - Michelle L Frits
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
| | - Christine K Iannaccone
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
| | - Hiroto Hatabu
- Center for Pulmonary Functional Imaging, Brigham and Women's Hospital, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Mizuki Nishino
- Center for Pulmonary Functional Imaging, Brigham and Women's Hospital, Boston, MA; Department of Radiology, Brigham and Women's Hospital, Boston, MA
| | - Michael E Weinblatt
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
| | - Dana P Ascherman
- Division of Rheumatology, University of Miami Miller School of Medicine, Miami FL
| | - George R Washko
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gary M Hunninghake
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Channing Laboratory, Brigham and Women's Hospital, Boston, MA
| | - Augustine M K Choi
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Nancy A Shadick
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA
| | - Ivan O Rosas
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Lovelace Respiratory Research Institute, Albuquerque, NM.
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315
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Anand AS, Joseph PB, Vera-Vazquez E. A case of pulmonary fibrosis associated with rheumatoid arthritis, scleroderma sine scleroderma and ANCA associated vasculitis. SPRINGERPLUS 2014; 3:513. [PMID: 25279305 PMCID: PMC4169781 DOI: 10.1186/2193-1801-3-513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 09/05/2014] [Indexed: 11/16/2022]
Abstract
Introduction Diffuse parenchymal lung disease (DPLD) may be idiopathic or may be due to known associations such as autoimmune diseases. The prognosis in cases associated with autoimmune diseases depends on many factors such as histopathology, baseline lung function, auto-antibody level, et cetera. DPLD and its prognosis is worse in patients with overlap syndromes. Case description We present a rare case of a 71 year old Caucasian lady with gradually worsening pulmonary fibrosis secondary to an overlap syndrome with rheumatoid arthritis (RA), scleroderma sine scleroderma (SSS) and anti neutrophil cytoplasmic antibody (ANCA) associated vasculitis. Discussion and Evaluation In this paper, we share information from review of literature regarding DPLD associated with RA, systemic sclerosis (SSc) and ANCA associated vasculitis. Details of our discussion include prognostic factors, histology and radiographic features of these individual disease entities. Conclusion Since pulmonary fibrosis in overlap syndromes has a poor prognosis, extensive work up should be performed even when clinical evidence of only one autoimmune disease is present.
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Affiliation(s)
| | - Priya Brian Joseph
- Lakeland Rheumatology, 3950 Hollywood Road, 280, St Joseph, MI 49085 USA
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316
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Rojas-Serrano J, Mateos-Toledo H, Mejía M. Methotrexate and Lung Disease in Rheumatoid Arthritis: Comment on the Article by Conway et al. Arthritis Rheumatol 2014; 66:2641-2. [DOI: 10.1002/art.38733] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Mayra Mejía
- Instituto Nacional de Enfermedades Respiratorias; Mexico City Mexico
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317
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Harlow L, Gochuico BR, Rosas IO, Doyle TJ, Osorio JC, Travers TS, Camacho CC, Oddis CV, Ascherman DP. Anti-citrullinated heat shock protein 90 antibodies identified in bronchoalveolar lavage fluid are a marker of lung-specific immune responses. Clin Immunol 2014; 155:60-70. [PMID: 25150019 DOI: 10.1016/j.clim.2014.08.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 06/20/2014] [Accepted: 08/11/2014] [Indexed: 11/24/2022]
Abstract
Previous work has demonstrated a correlation between serum anti-citrullinated HSP90 antibodies and rheumatoid arthritis-associated interstitial lung disease (RA-ILD). To further investigate this potential pathogenic relationship, we used ELISA-based techniques to assess anti-citrullinated HSP90 antibody profiles in bronchoalveolar lavage fluid (BALF) of patients with different stages of RA-ILD. 9/21 RA-derived BALF specimens demonstrated IgG and/or IgA antibodies targeting citrullinated HSP90 proteins/peptides, highlighting disease specific responses (with a predilection for RA-ILD) that did not occur in IPF patients (0/5) or healthy control subjects (0/5). Comparison of antibody profiles between BALF and matching serum specimens revealed various recognition patterns favoring predominant production of anti-citrullinated HSP90 antibodies within the lung microenvironment-further supporting the connection between this antibody specificity and parenchymal lung disease. Equally important, qualitative as well as quantitative differences in anti-citrullinated HSP90 profiles between BALF and serum indicate that the lung plays a direct role in shaping the immune repertoire of RA/RA-ILD.
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Affiliation(s)
- Lisa Harlow
- Department of Medicine, Division of Rheumatology, University of Miami Miller School of Medicine, Miami, FL 33136, United States
| | | | - Ivan O Rosas
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Tracy J Doyle
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Juan C Osorio
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Timothy S Travers
- Department of Computational and Systems Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Carlos C Camacho
- Department of Computational and Systems Biology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Chester V Oddis
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, United States
| | - Dana P Ascherman
- Department of Medicine, Division of Rheumatology, University of Miami Miller School of Medicine, Miami, FL 33136, United States.
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318
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Westhoff M. [Acute on chronic respiratory failure in interstitial pneumonias]. Med Klin Intensivmed Notfmed 2014; 110:188-96. [PMID: 25125234 DOI: 10.1007/s00063-014-0388-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 03/20/2014] [Accepted: 05/11/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute exacerbations of idiopathic interstitial pneumonias and exacerbations of pleuropulmonary disease in connective tissue diseases are associated with a high mortality. DIAGNOSTIC PROCEDURES They have to be differentiated from respiratory failure in patients with interstitial lung disease as a result of infections, pulmonary embolism, cardiac failure and drug toxicity, because the latter can be treated causally. The extent and the invasivity of diagnostic procedures have to be adopted to the patient's situation. A rapid diagnosis is important in order to initiate therapies (antibiotics, anticoagulation, immunosuppression) in treatable causes of exacerbations. IMPORTANCE OF VENTILATION The prognosis for patients who are under invasive mechanical ventilation in acute exacerbations of interstitial lung disease is poor. Especially in acute exacerbations of idiopathic pulmonary fibrosis (IPF), there is no general recommendation for either invasive or for noninvasive ventilation. In acute exacerbations of other subtypes of interstitial pneumonia, either idiopathic or as a pulmonary manifestation of connective tissue disease, and in all secondary exacerbations of idiopathic interstitial pneumonias which offer further treatment options, the decision about mechanical ventilation requires a differentiated assessment. LUNG TRANSPLANTATION In younger patients with interstitial lung disease and a progressive disease, indication for lung transplantation should be made early and before an exacerbation. If patients listed for lung transplantation experience an acute exacerbation, bridging-to-transplant has to be discussed with the transplant unit. In cases without further causal treatment options palliative care must be initiated.
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Affiliation(s)
- M Westhoff
- Klinik für Pneumologie, Schlaf- und Beatmungsmedizin, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Theo-Funccius-Str. 1, 58675, Hemer, Deutschland,
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319
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Enomoto Y, Takemura T, Hagiwara E, Iwasawa T, Okudela K, Yanagawa N, Baba T, Sakai F, Fukuda Y, Nagaoka S, Ogura T. Features of usual interstitial pneumonia in patients with primary Sjögren׳s syndrome compared with idiopathic pulmonary fibrosis. Respir Investig 2014; 52:227-235. [PMID: 24998369 DOI: 10.1016/j.resinv.2014.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 02/18/2014] [Accepted: 02/23/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND The different characteristics of usual interstitial pneumonia in patients with primary Sjögren׳s syndrome (UIP/pSS) compared with idiopathic pulmonary fibrosis (UIP/IPF) are not fully understood. This study aimed to compare characteristics, prognosis, and treatment responses in these patients. METHODS Among 129 consecutive patients who underwent surgical lung biopsy to diagnose diffuse lung diseases at Kanagawa Cardiovascular and Respiratory Center between 1998 and 2002, we identified 10 and 19 patients with UIP/pSS and UIP/IPF, respectively. Baseline characteristics, chest high-resolution computed tomography (HRCT) and pathological findings, and the clinical course were compared between the two groups. Responses to immunosuppressive therapy were analyzed by comparing pulmonary function and clinical status before and one year after treatment initiation. RESULTS More patients in the UIP/pSS group tended to be female and older than those in the UIP/IPF group (mean age, 68 years vs. 62 years). In addition, they more commonly exhibited enlarged mediastinal lymph nodes and bronchial wall thickening on HRCT. Pathologically, in the UIP/pSS group, interstitial inflammation, plasma cell infiltration, lymphoid follicles with germinal centers, cysts, bronchiolitis, and pleuritis were significantly more prominent, whereas smooth muscle hyperplasia and fibroblastic foci were milder (all P<0.05). The prognosis was better for UIP/pSS compared with UIP/IPF patients (P=0.01). In addition, immunosuppressive therapy provided better disease control for those with UIP/pSS (83%, 5/6) compared UIP/IPF (7%, 1/15). CONCLUSION This study identified distinct clinical, radiological, and pathological characteristics of UIP/pSS compared with UIP/IPF. Immunosuppressive treatment could be a therapeutic option for UIP/pSS.
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Affiliation(s)
- Yasunori Enomoto
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1, Tomioka-Higashi, Kanazawa-ku, Yokohama 236-0051, Japan.
| | - Tamiko Takemura
- Department of Pathology, Japanese Red Cross Medical Center, 4-1-22, Hiroo, Shibuya-ku, Tokyo 150-8935, Japan.
| | - Eri Hagiwara
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1, Tomioka-Higashi, Kanazawa-ku, Yokohama 236-0051, Japan.
| | - Tae Iwasawa
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, 6-16-1, Tomioka-Higashi, Kanazawa-ku, Yokohama 236-0051, Japan.
| | - Koji Okudela
- Department of Pathobiology, Yokohama City University Graduate School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
| | - Noriyo Yanagawa
- Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22, Honkomagome, Bunkyo-ku, Tokyo 113-8677, Japan.
| | - Tomohisa Baba
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1, Tomioka-Higashi, Kanazawa-ku, Yokohama 236-0051, Japan.
| | - Fumikazu Sakai
- Department of Diagnostic Radiology, Saitama International Medical Center, Saitama Medical University, 1298, Yamane, Hidaka, Saitama 350-1298, Japan.
| | - Yuh Fukuda
- Department of Diagnostic Pathology, Itabashi Chuo Medical Center, 2-12-7, Azusawa, Itabashi-ku, Tokyo 174-0051, Japan.
| | - Shouhei Nagaoka
- Department of Rheumatology, Yokohama Minami Kyosai Hospital, 1-21-1, Mutsuura-Higashi, Kanazawa-ku, Yokohama 236-0037, Japan.
| | - Takashi Ogura
- Department of Respiratory Medicine, Kanagawa Cardiovascular and Respiratory Center, 6-16-1, Tomioka-Higashi, Kanazawa-ku, Yokohama 236-0051, Japan.
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320
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Pérez-Dórame R, Mejía M, Mateos-Toledo H, Rojas-Serrano J. Rheumatoid arthritis-associated interstitial lung disease: lung inflammation evaluated with high resolution computed tomography scan is correlated to rheumatoid arthritis disease activity. ACTA ACUST UNITED AC 2014; 11:12-6. [PMID: 24913966 DOI: 10.1016/j.reuma.2014.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 02/08/2014] [Accepted: 02/22/2014] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To describe the association between rheumatoid arthritis disease activity (RA) and interstitial lung damage (inflammation and fibrosis), in a group of patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD). METHODS A retrospective study of RA patients with interstitial lung disease (restrictive pattern in lung function tests and evidence of interstitial lung disease in high resolution computed tomography (HRCT)). Patients were evaluated to exclude other causes of pulmonary disease. RA disease activity was measured with the CDAI index. Interstitial lung inflammation and fibrosis were determined by Kazerooni scale. We compared Kazerooni ground-glass score with the nearest CDAI score to HRCT date scan of the first medical evaluation at our institution. In nine patients, we compared the first ground-glass score with a second one after treatment with DMARDs and corticosteroids. Spearman's rank correlation coefficient was used to evaluate association between RA disease activity and the Kazerooni ground-glass and fibrosis scores. RESULTS Thirty-four patients were included. A positive correlation between CDAI and ground-glass scores was found (rs=0.3767, P<0.028). Fibrosis and CDAI scores were not associated (rs=-0.0747, P<0.6745). After treatment, a downward tendency in the ground-glass score was observed (median [IQR]): (2.33 [2,3] vs. 2 [1.33-2.16]), P<0.056, along with a lesser CDAI score (27 [8-43] vs. 9 [5-12]), P<0.063. CONCLUSION There is a correlation between RA disease activity and ground-glass appearance in the HRCT of RA-ILD patients. These results suggest a positive association between RA disease activity and lung inflammation in RA-ILD.
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Affiliation(s)
- Renzo Pérez-Dórame
- Servicio Clínico de Enfermedades Intersticiales del Pulmón Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Mexico
| | - Mayra Mejía
- Servicio Clínico de Enfermedades Intersticiales del Pulmón Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Mexico
| | - Heidegger Mateos-Toledo
- Servicio Clínico de Enfermedades Intersticiales del Pulmón Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Mexico
| | - Jorge Rojas-Serrano
- Servicio Clínico de Enfermedades Intersticiales del Pulmón, Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico.
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321
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Watanabe E, Kawamura T, Mochizuki Y, Nakahara Y, Sasaki S, Okamoto A, Higashino T. Consolidation with a twisted appearance along the airways: a report of five cases of interstitial pneumonia. Respir Investig 2014; 52:213-218. [PMID: 24853025 DOI: 10.1016/j.resinv.2013.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 12/17/2013] [Accepted: 12/18/2013] [Indexed: 06/03/2023]
Abstract
High-resolution CT showed areas of airspace consolidation with a twisted appearance of the airways, along with areas of peribronchial ground-glass attenuation and traction bronchiectasis, in five patients with interstitial pneumonia. These areas of airspace consolidation were termed "twisted consolidation" (TwC). The five patients included two patients receiving treatment for rheumatoid arthritis (RA), one patient with newly diagnosed RA, and one patient who subsequently showed RA. Three patients showed improvement after steroid administration. An association of TwC with RA is suspected, but further studies are necessary.
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Affiliation(s)
- Etsuko Watanabe
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Tetsuji Kawamura
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Yoshiro Mochizuki
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Yasuharu Nakahara
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Shin Sasaki
- Department of Respiratory Medicine, National Hospital Organization Himeji Medical Center, 68 Honmachi, Himeji-city, Hyogo 670-8520, Japan.
| | - Akira Okamoto
- Department of Rheumatology, National Hospital Organization Himeji Medical Center, Hyogo, Japan.
| | - Takanori Higashino
- Department of Radiology, National Hospital Organization Himeji Medical Center, Hyogo, Japan.
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322
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Kelly CA, Saravanan V, Nisar M, Arthanari S, Woodhead FA, Price-Forbes AN, Dawson J, Sathi N, Ahmad Y, Koduri G, Young A. Rheumatoid arthritis-related interstitial lung disease: associations, prognostic factors and physiological and radiological characteristics--a large multicentre UK study. Rheumatology (Oxford) 2014; 53:1676-82. [PMID: 24758887 DOI: 10.1093/rheumatology/keu165] [Citation(s) in RCA: 339] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The prevalence of interstitial lung disease (ILD) in RA is ∼5%. Previous work identified increasing age, active articular disease and articular damage as risk factors for RA-associated ILD (RA-ILD). The roles of high-resolution CT (HRCT) and lung function testing in defining the nature and extent of pulmonary involvement have recently been explored. This study is the first to examine predictive and prognostic factors for the development of RA-ILD and to report on the physiological and radiological characteristics of the condition from a large multicentre UK network. METHODS We collected data from centres across the UK on patients with both RA and ILD (proved on HRCT) diagnosed over a 25-year period from 1987 to 2012 using a standard pro forma. Potential predictors of RA-ILD were analysed. Baseline lung function data were recorded and related to HRCT findings. We analysed HRCT for subtype and extent of lung involved and examined the relationship between these and both all-cause and pulmonary mortality. We compared our results with case controls matched for age and gender using computer-generated selection from the RA population from one contributing centre. RESULTS A total of 230 patients were identified from across the UK with proven RA-ILD diagnosed over 25 years. Median age at diagnosis was 64 years and the male:female ratio was 1:1.09. Univariate analysis showed anti-CCP antibody titres to be the single most strongly associated predictor of RA-ILD. Male gender, age at onset, smoking and RF were all independently associated with RA-ILD on multivariate analysis. Vital capacity (VC) was preserved in limited disease but reduced in extensive disease, while gas transfer was reduced in both. Usual interstitial pneumonia (UIP) was the most common subtype on HRCT and both this and extensive disease were associated with increased all-cause mortality. CONCLUSION This is the largest study of RA-ILD in the UK. Anti-CCP antibodies were strongly associated with RA-ILD in both sexes. Smoking was strongly associated with ILD in males, which may explain the higher frequency of RA-ILD in men. The predominant HRCT pattern was UIP and most patients had limited disease at presentation. The presence of UIP and extensive disease are associated with increased mortality. Baseline gas transfer is a useful screening tool for ILD, while the preservation of VC at baseline might predict limited disease on HRCT.
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Affiliation(s)
- Clive A Kelly
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK.
| | - Vadivelu Saravanan
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Mohamed Nisar
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Subha Arthanari
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Felix A Woodhead
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Alec N Price-Forbes
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Julie Dawson
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Navtej Sathi
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Yasmeen Ahmad
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Gouri Koduri
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
| | - Adam Young
- Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, Department of Rheumatology, Burton Hospital, Burton on Trent, Department of Chest Medicine, Coventry and Warwickshire Hospital, Coventry, Department of Rheumatology, St Helens Hospital, Department of Rheumatology, Wrightington Hospital, St Helens, Department of Rheumatology, Betsi Cadwaldr University Health Board, Llandudno and Department of Rheumatology, St Albans City Hospital, St Albans, UK
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323
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Doyle TJ, Lee JS, Dellaripa PF, Lederer JA, Matteson EL, Fischer A, Ascherman DP, Glassberg MK, Ryu JH, Danoff SK, Brown KK, Collard HR, Rosas IO. A roadmap to promote clinical and translational research in rheumatoid arthritis-associated interstitial lung disease. Chest 2014; 145:454-463. [PMID: 24590021 DOI: 10.1378/chest.13-2408] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Rheumatoid arthritis (RA) is a systemic inflammatory disorder affecting approximately 1.3 million adults in the United States. Approximately 10% of these individuals with RA have clinically evident interstitial lung disease (RA-ILD), and an additional one-third demonstrate subclinical ILD on chest CT scan. The risk of death for individuals with RA-ILD is three times higher than for patients with RA without ILD, with a median survival after ILD diagnosis of only 2.6 years. Despite the high prevalence and mortality of RA-ILD, little is known about its molecular features and its natural history. At present, we lack a standard validated approach to the definition, diagnosis, risk stratification, and management of RA-ILD. In this perspective, we discuss the importance of clinical and translational research and how ongoing research efforts can address important gaps in our knowledge over the next few years. Furthermore, recommendations are made to design multicenter collaborative studies that will expedite the development of clinical trials designed to decrease the significant morbidity and mortality associated with RA-ILD.
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Affiliation(s)
- Tracy J Doyle
- Division of Pulmonary and Critical Care Medicine Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Joyce S Lee
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco School of Medicine, San Francisco, CA
| | - Paul F Dellaripa
- Division of Rheumatology, Immunology, and Allergy Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James A Lederer
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine, Rochester, MN
| | - Aryeh Fischer
- Division of Rheumatology, National Jewish Health and University of Colorado, Denver, CO
| | - Dana P Ascherman
- Division of Rheumatology, University of Miami Miller School of Medicine, Miami, FL
| | - Marilyn K Glassberg
- Division of Pulmonary Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN
| | - Sonye K Danoff
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin K Brown
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO
| | - Harold R Collard
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco School of Medicine, San Francisco, CA
| | - Ivan O Rosas
- Lovelace Respiratory Research Institute, Albuquerque, NM.
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324
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Kono M, Nakamura Y, Enomoto N, Hashimoto D, Fujisawa T, Inui N, Maekawa M, Suda T, Colby TV, Chida K. Usual interstitial pneumonia preceding collagen vascular disease: a retrospective case control study of patients initially diagnosed with idiopathic pulmonary fibrosis. PLoS One 2014; 9:e94775. [PMID: 24736601 PMCID: PMC3988132 DOI: 10.1371/journal.pone.0094775] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 03/19/2014] [Indexed: 01/26/2023] Open
Abstract
Background The aim of this study was to evaluate the cumulative incidence and the predictive factors for collagen vascular disease (CVD) in patients initially diagnosed with idiopathic pulmonary fibrosis (IPF), and to examine the features of patients who then developed CVD. Methods This was a retrospective review of 111 consecutive patients with IPF diagnosed at our institution. None of the patients fulfilled any of the CVD criteria from the American College of Rheumatology (ACR) within 6 months or more after the diagnosis of IPF. Results Ten patients (9.0%) developed CVD during the follow-up period: four had rheumatoid arthritis (RA); four had microscopic polyangiitis (MPA); one had systemic sclerosis (SSc); and one had SSc and Sjogren’s syndrome (SjS). The mean time until CVD diagnosis was 3.9 years. The cumulative incidences of CVD at 1, 5, and 10 years were 0.91%, 9.85%, and 15.5%, respectively. Patients who developed CVD were significantly younger, more likely to be women and had a better prognosis than those with IPF. Cox proportional hazards regression analysis showed that female sex and the presence of lymphoid aggregates with germinal centers were significantly associated with the occurrence of CVD in patients initially diagnosed with IPF. Conclusions CVD is an important underlying condition in IPF, and shows better prognosis. The possibility of the development of CVD should remain a consideration in the follow-up of IPF.
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Affiliation(s)
- Masato Kono
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan; Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Noriyuki Enomoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Dai Hashimoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Inui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masato Maekawa
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Thomas V Colby
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, Arizona, United Sates of America
| | - Kingo Chida
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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325
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Wells AU, Antoniou KM. The Prognostic Value of the GAP Model In Chronic Interstitial Lung Disease. Chest 2014; 145:672-674. [DOI: 10.1378/chest.13-2908] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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326
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Glaspole IN, Westall GP, Goh NSL, Holland AE. Cyclophosphamide for connective tissue disease-associated interstitial lung disease. Hippokratia 2014. [DOI: 10.1002/14651858.cd010908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ian N Glaspole
- Alfred Hospital; Department of Allergy, Immunology and Respiratory Medicine; Commercial Road Melbourne Victoria Australia 3004
| | - Glen P Westall
- Alfred Hospital; Department of Allergy, Immunology and Respiratory Medicine; Commercial Road Melbourne Victoria Australia 3004
| | - Nicole SL Goh
- Alfred Hospital; Department of Allergy, Immunology and Respiratory Medicine; Commercial Road Melbourne Victoria Australia 3004
| | - Anne E Holland
- La Trobe University; School of Physiotherapy; Melbourne Victoria Australia 3086
- Alfred Health; Department of Physiotherapy; Melbourne Victoria Australia 3181
- Institute for Breathing and Sleep; Austin Health Melbourne Victoria Australia 3084
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327
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Song JW. Interstitial Lung Disease in Connective Tissue Disease. JOURNAL OF RHEUMATIC DISEASES 2014. [DOI: 10.4078/jrd.2014.21.6.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jin Woo Song
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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328
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Assayag D, Lubin M, Lee JS, King TE, Collard HR, Ryerson CJ. Predictors of mortality in rheumatoid arthritis-related interstitial lung disease. Respirology 2013; 19:493-500. [PMID: 24372981 DOI: 10.1111/resp.12234] [Citation(s) in RCA: 116] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/17/2013] [Accepted: 11/23/2013] [Indexed: 12/19/2022]
Abstract
Rheumatoid arthritis-associated interstitial lung disease (RA-ILD) has a heterogeneous clinical presentation and disease course. Establishing prognosis for these patients is challenging. Identifying the factors that predict mortality in patients with RA-ILD could help guide management. A detailed systematic review was conducted in order to identify individual variables that predict mortality in RA-ILD. A literature review was performed using keywords and medical subject headings to identify all articles relating to the prognosis of RA-ILD. Studies were included if they identified predictors of mortality in adults with RA-ILD, were published in English, and included at least 10 patients with RA-ILD. Two authors independently reviewed each citation and extracted data from all studies meeting inclusion criteria. Any differences were then resolved by consensus. A total of 10 studies met our inclusion criteria. All were observational cohort studies of variable quality. Mean age of reported patients ranged from 55 to 69 years, and 41.7% of all patients were male. Median survival ranged from 3.2 to 8.1 years. Significant predictors of mortality on multivariate analysis were older age, male gender, lower diffusion capacity for carbon monoxide, extent of fibrosis, and the presence of usual interstitial pneumonia pattern. Mortality in RA-ILD is associated with several patient- and ILD-specific variables; however, previous studies are of low quality.
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Affiliation(s)
- Deborah Assayag
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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329
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Solomon JJ, Fischer A. Connective Tissue Disease-Associated Interstitial Lung Disease. J Intensive Care Med 2013; 30:392-400. [DOI: 10.1177/0885066613516579] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 10/15/2013] [Indexed: 01/13/2023]
Abstract
The connective tissue diseases (CTDs) are a group of systemic disorders characterized by autoimmunity and autoimmune-mediated organ damage. The lung is a frequent target and all components of the respiratory system are at risk. Interstitial lung disease (ILD) represents a broad group of diffuse parenchymal lung injury patterns characterized by varying degrees of inflammation and fibrosis, is a common manifestation of CTD particularly common in systemic sclerosis, polymyositis/dermatomyositis, and rheumatoid arthritis, and is a leading cause of significant morbidity and mortality. The lung injury patterns of CTD-associated ILD (CTD-ILD) mirror those of idiopathic interstitial pneumonia and may arise at any time during the course of the CTD or may be the first manifestation of CTD. Patients with CTD that present with respiratory failure often present significant diagnostic dilemmas. Thorough and comprehensive assessments to exclude respiratory *infection, acute interstitial pneumonia, medication toxicity, pulmonary embolism, cardiac dysfunction, and diffuse alveolar hemorrhage are the fundamental components for the evaluation of such patients. Furthermore, patients with CTD are also at risk of acute exacerbations of underlying ILD. Acute exacerbations are manifested by subacute respiratory deterioration with worsening hypoxemia in the setting of new radiographic abnormalities. The prognosis of patients with CTD having respiratory failure is often quite poor, highlighting the need for prompt and thorough clinical assessments to determine the underlying etiology and implementation of appropriate therapeutic strategies.
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Affiliation(s)
- Joshua J. Solomon
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
| | - Aryeh Fischer
- Department of Medicine, National Jewish Health, Denver, Colorado, USA
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330
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Abstract
Interstitial lung disease (ILD) is a common extra-articular manifestation associated with increased morbidity and mortality in patients with rheumatoid arthritis (RA). Early case reports of serious respiratory adverse events (SRAEs) following treatment with anti-TNF agents have led to concerns about biologic therapy in patients with RA-associated ILD (RA-ILD), and a tendency for biologic agents targeting factors other than TNF to be prescribed in such patients. At present, the appropriateness of such decisions is not clear. Given that the therapeutic goal for RA is remission, clinicians increasingly face the challenge of choosing the optimal biologic agent in patients with RA-ILD and uncontrolled joint disease. However, no evidence-based guidelines exist to guide physicians in deciding whether to commence biologic therapy in this setting, or in selecting which drug is most appropriate. Herein, we review the evidence for the comparative pulmonary safety of anti-TNF agents and non-TNF-targeting biologic agents in RA-ILD. In addition, we propose a framework for assessment of baseline disease severity to guide treatment decisions, and for monitoring during therapy. Because of substantial gaps in the available evidence, we also describe a research agenda aimed at obtaining data that will help inform future clinical practice.
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331
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Assayag D, Elicker BM, Urbania TH, Colby TV, Kang BH, Ryu JH, King TE, Collard HR, Kim DS, Lee JS. Rheumatoid arthritis-associated interstitial lung disease: radiologic identification of usual interstitial pneumonia pattern. Radiology 2013; 270:583-8. [PMID: 24126367 DOI: 10.1148/radiol.13130187] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To determine the accuracy of computed tomography (CT) in identifying the histopathologic usual interstitial pneumonia (UIP) pattern in rheumatoid arthritis-associated interstitial lung disease (RA-ILD). MATERIALS AND METHODS All patients were enrolled into institutional review board-approved longitudinal cohorts at their respective institution, and informed consent was obtained at the time of enrollment. Images of patients with surgical lung biopsy-proved RA-ILD (n = 69) were collected from three tertiary care centers. Two experienced thoracic radiologists independently reviewed the CT scans. The CT pattern was categorized as definite UIP, possible UIP, or inconsistent with UIP in accordance with published criteria. Findings of biopsies were reviewed by an experienced lung pathologist. The sensitivity and specificity of definite CT UIP pattern to histopathologic UIP pattern were determined. The agreement between radiologists was assessed by calculating a κ score. RESULTS The histopathologic UIP pattern was present in 42 of 69 (61%) patients. Men were more likely than women to have a histopathologic UIP pattern (P = .02). Twenty patients (29%, 20 of 69) had a definite UIP pattern on CT scans. The specificity of CT UIP pattern was 96% (26 of 27; 95% confidence interval [CI]: 81%, 100%), with a negative predictive value of 53% (26 of 49). The sensitivity of CT UIP pattern was 45% (19 of 42; 95% CI: 30%, 61%), with a positive predictive value of 95% (19 of 20). The agreement between radiologists for definite UIP pattern versus not was 87% (κ = 0.67, P < .0001). CONCLUSION Definite UIP pattern on a CT scan in RA-ILD is highly specific and moderately sensitive for histopathologic UIP pattern. CT can therefore help accurately identify the UIP pattern in RA-ILD.
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Affiliation(s)
- Deborah Assayag
- From the Departments of Medicine (D.A., T.E.K., H.R.C., J.S.L.) and Radiology (B.M.E., T.H.U.), University of California, San Francisco, Calif; Department of Laboratory Medicine and Pathology, Mayo Clinic, Phoenix, Ariz (T.V.C.); Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan, 388-1 Pungnap-2dong, Songpa-gu, Seoul 138-736, Korea (B.H.K., D.S.K.); and Department of Medicine, Mayo Clinic, Rochester, Minn (J.H.R.)
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332
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Bryson T, Sundaram B, Khanna D, Kazerooni EA. Connective tissue disease-associated interstitial pneumonia and idiopathic interstitial pneumonia: similarity and difference. Semin Ultrasound CT MR 2013; 35:29-38. [PMID: 24480141 DOI: 10.1053/j.sult.2013.10.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Interstitial lung diseases (ILDs) are increasingly recognized in patients with systemic diseases. Patients with early ILD changes may be asymptomatic. Features of ILD overlap among systemic diseases and with idiopathic variety. High-resolution computed tomography plays a central role in diagnosing ILDs. Imaging features are often nonspecific. Therapy- and complication-related lung changes would pose difficulty in diagnosing and classifying an ILD. Biology and prognosis of secondary ILDs may differ between different disease-related ILDs and idiopathic variety. Combination of clinical features, serological tests, pulmonary and extrapulmonary imaging findings, and pathology findings may help to diagnose ILDs.
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Affiliation(s)
- Thomas Bryson
- Department of Diagnostic Radiology, University of Michigan Health System, Ann Arbor, MI
| | - Baskaran Sundaram
- Department of Diagnostic Radiology, University of Michigan Health System, Ann Arbor, MI.
| | - Dinesh Khanna
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Ella A Kazerooni
- Department of Diagnostic Radiology, University of Michigan Health System, Ann Arbor, MI
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333
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Walsh SLF, Sverzellati N, Devaraj A, Keir GJ, Wells AU, Hansell DM. Connective tissue disease related fibrotic lung disease: high resolution computed tomographic and pulmonary function indices as prognostic determinants. Thorax 2013; 69:216-22. [PMID: 24127020 DOI: 10.1136/thoraxjnl-2013-203843] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine high resolution computed tomography (HRCT) patterns and pulmonary function indices which are associated with increased mortality in patients with connective tissue disease related fibrotic lung disease (CTD-FLD). METHODS HRCTs from 168 patients with CTD-FLD were scored by 2 observers for a variety of HRCT patterns and traction bronchiectasis. A radiological diagnosis of usual interstitial pneumonia (UIP), fibrotic non-specific interstitial pneumonia (NSIP) or indeterminate was also assigned. Using Cox regression analysis, associations with mortality were identified. Honeycombing and traction bronchiectasis scores were converted to binary absence/presence scores and also tested. A subgroup analysis of patients with biopsy material (n=51) was performed by classifying patients according to radiological and histopathological diagnoses, as concordant UIP, discordant UIP and fibrotic NSIP. The prognostic separation of this classification was also evaluated. RESULTS Severity of traction bronchiectasis (HR 1.10, p=0.001, 95% CIs 1.04 to 1.17), increasing extent of honeycombing (HR 1.08, p=0.021, 95% CI 1.03 to 1.13) and reduction in DLco (HR 0.97, p=0.013, 95% CI 0.95 to 0.99) were independently associated with increased mortality. Interobserver agreement and prognostic strength were higher for binary traction bronchiectasis scores (weighted κ (κw)=0.69, HR 4.00, p=0.001, 95%CI 1.19 to 13.38), than binary honeycombing scores (κw=0.50, HR 2.87, p=0.022, 95% CI 1.53 to 5.43). The radiological-histopathological classification was strongly associated with increased mortality (HR 2.74, p<0.001, 95% CI 1.57 to 4.77) and patients with discordant UIP had a better prognosis than concordant UIP but worse prognosis than fibrotic NSIP. CONCLUSIONS Severity of traction bronchiectasis, extent of honeycombing and DLco are strongly associated with mortality in CTD-FLD. Interobserver agreement for traction bronchiectasis is higher than for honeycombing. In CTD-FLD, radiological diagnosis has survival implications in biopsy proven UIP.
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Affiliation(s)
- Simon L F Walsh
- Department of Radiology, Royal Brompton Hospital, , London, UK
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334
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O'Dwyer DN, Armstrong ME, Cooke G, Dodd JD, Veale DJ, Donnelly SC. Rheumatoid Arthritis (RA) associated interstitial lung disease (ILD). Eur J Intern Med 2013; 24:597-603. [PMID: 23916467 DOI: 10.1016/j.ejim.2013.07.004] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 07/04/2013] [Accepted: 07/06/2013] [Indexed: 01/08/2023]
Abstract
Rheumatoid Arthritis (RA) is the most common Connective Tissue Disease (CTD) and represents an increasing burden on global health resources. Interstitial lung disease (ILD) has been recognised as a complication of RA but its potential for mortality and morbidity has arguably been under appreciated for decades. New studies have underscored a significant lifetime risk of ILD development in RA. Contemporary work has identified an increased risk of mortality associated with the Usual Interstitial Pneumonia (UIP) pattern which shares similarity with the most devastating of the interstitial pulmonary diseases, namely Idiopathic Pulmonary Fibrosis (IPF). In this paper, we discuss recent studies highlighting the associated increase in mortality in RA-UIP. We explore associations between radiological and histopathological features of RA-ILD and the prognostic implications of same. We emphasise the need for translational research in this area given the growing burden of RA-ILD. We highlight the importance of the respiratory physician as a key stakeholder in the multidisciplinary management of this disorder. RA-ILD focused research offers the opportunity to identify early asymptomatic disease and define the natural history of this extra articular manifestation. This may provide a unique opportunity to define key regulatory fibrotic events driving progressive disease. We also discuss some of the more challenging and novel aspects of therapy for RA-ILD.
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Affiliation(s)
- David N O'Dwyer
- School of Medicine and Medical Science, College of Life Sciences, UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Belfield, Dublin 4, Ireland; National Pulmonary Fibrosis Referral Centre at St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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335
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The multifaceted aspects of interstitial lung disease in rheumatoid arthritis. BIOMED RESEARCH INTERNATIONAL 2013; 2013:759760. [PMID: 24205507 PMCID: PMC3800606 DOI: 10.1155/2013/759760] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 02/07/2023]
Abstract
Interstitial lung disease (ILD) is a relevant extra-articular manifestation of rheumatoid arthritis (RA) that may occur either in early stages or as a complication of long-standing disease. RA related ILD (RA-ILD) significantly influences the quoad vitam prognosis of these patients. Several histopathological patterns of RA-ILD have been described: usual interstitial pneumonia (UIP) is the most frequent one, followed by nonspecific interstitial pneumonia (NSIP); other patterns are less commonly observed. Several factors have been associated with an increased risk of developing RA-ILD. The genetic background plays a fundamental but not sufficient role; smoking is an independent predictor of ILD, and a correlation with the presence of rheumatoid factor and anti-cyclic citrullinated peptide antibodies has also been reported. Moreover, both exnovo occurrence and progression of ILD have been related to drug therapies that are commonly prescribed in RA, such as methotrexate, leflunomide, anti-TNF alpha agents, and rituximab. A greater understanding of the disease process is necessary in order to improve the therapeutic approach to ILD and RA itself and to reduce the burden of this severe extra-articular manifestation.
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336
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Hozumi H, Nakamura Y, Johkoh T, Sumikawa H, Colby TV, Kono M, Hashimoto D, Enomoto N, Fujisawa T, Inui N, Suda T, Chida K. Acute exacerbation in rheumatoid arthritis-associated interstitial lung disease: a retrospective case control study. BMJ Open 2013; 3:e003132. [PMID: 24038004 PMCID: PMC3773638 DOI: 10.1136/bmjopen-2013-003132] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To investigate the risk factors and prognosis associated with acute exacerbation (AE) in patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD). DESIGN A retrospective case-control study. SETTING A single academic hospital. PARTICIPANTS 51 consecutive patients diagnosed with RA-ILD between 1995 and 2012. All patients fulfilled the diagnostic criteria of the American College of Rheumatology for RA. ILD was diagnosed on the basis of clinical presentation, pulmonary function tests, high-resolution CT (HRCT) findings and lung biopsy findings. MAIN OUTCOME MEASURES Overall survival and cumulative AE incidence were analysed using Kaplan-Meier method. Cox hazards analysis was used to determine significant variables associated with AE occurrence and survival status. RESULTS A total of 11 patients (22%) developed AE, with an overall 1-year incidence of 2.8%. Univariate analysis revealed that older age at ILD diagnosis (HR 1.11; 95% CI 1.02 to 1.21; p=0.01), usual interstitial pneumonia (UIP) pattern on HRCT (HR 1.95; 95% CI 1.07 to 3.63; p=0.03) and methotrexate usage (HR 3.04; 95% CI 1.62 to 6.02; p=0.001) were associated with AE. Of 11 patients who developed AE during observation period, 7 (64%) died of initial AE. In survival, AE was a prognostic factor for poor outcome (HR 2.47; 95% CI 1.39 to 4.56; p=0.003). CONCLUSIONS In patients with RA-ILD, older age at ILD diagnosis, UIP pattern on HRCT and methotrexate usage are associated with the development of AE. Furthermore, AE has a serious impact on their survival.
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Affiliation(s)
- Hironao Hozumi
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yutaro Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takeshi Johkoh
- Department of Radiology, Kinki Central Hospital of Mutual Aid Association of Public School Teachers, Itami-City, Hyogo, Japan
| | - Hiromitsu Sumikawa
- Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Thomas V Colby
- Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Masato Kono
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Dai Hashimoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Noriyuki Enomoto
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomoyuki Fujisawa
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Naoki Inui
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Takafumi Suda
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kingo Chida
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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337
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Asymptomatic preclinical rheumatoid arthritis-associated interstitial lung disease. Clin Dev Immunol 2013; 2013:406927. [PMID: 23983768 PMCID: PMC3747456 DOI: 10.1155/2013/406927] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/29/2013] [Accepted: 07/11/2013] [Indexed: 12/19/2022]
Abstract
Objective. Interstitial lung disease (ILD) is a common extra-articular manifestation of rheumatoid arthritis (RA) and a significant cause of morbidity and mortality. The objective of this study was to define high-resolution chest CT (HRCT) and pulmonary function test (PFT) abnormalities capable of identifying asymptomatic, preclinical forms of RA-ILD that may represent precursors to more severe fibrotic lung disease. Methods. We analyzed chest HRCTs in consecutively enrolled RA patients and subsequently classified these individuals as RA-ILD or RA-no ILD based on the presence/absence of ground glass opacification, septal thickening, reticulation, traction bronchiectasis, and/or honeycombing. Coexisting PFT abnormalities (reductions in percent predicted FEV1, FVC, TLC, and/or DLCO) were also used to further characterize occult respiratory defects. Results. 61% (63/103) of RA patients were classified as RA-ILD based on HRCT and PFT abnormalities, while 39% (40/103) were designated as RA-no ILD. 57/63 RA-ILD patients lacked symptoms of significant dyspnea or cough at the time of HRCT and PFT assessment. Compared with RA-no ILD, RA-ILD patients were older and had longer disease duration, higher articular disease activity, and more significant PFT abnormalities. Conclusion. HRCT represents an effective tool to detect occult/asymptomatic ILD that is highly prevalent in our unselected, university-based cohort of RA patients.
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338
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Vij R, Strek ME. Diagnosis and treatment of connective tissue disease-associated interstitial lung disease. Chest 2013; 143:814-824. [PMID: 23460159 DOI: 10.1378/chest.12-0741] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Interstitial lung disease (ILD) is one of the most serious pulmonary complications associated with connective tissue diseases (CTDs), resulting in significant morbidity and mortality. Although the various CTDs associated with ILD often are considered together because of their shared autoimmune nature, there are substantial differences in the clinical presentations and management of ILD in each specific CTD. This heterogeneity and the cross-disciplinary nature of care have complicated the conduct of prospective multicenter treatment trials and hindered our understanding of the development of ILD in patients with CTD. In this update, we present new information regarding the diagnosis and treatment of patients with ILD secondary to systemic sclerosis, rheumatoid arthritis, dermatomyositis and polymyositis, and Sjögren syndrome. We review information on risk factors for the development of ILD in the setting of CTD. Diagnostic criteria for CTD are presented as well as elements of the clinical evaluation that increase suspicion for CTD-ILD. We review the use of medications in the treatment of CTD-ILD. Although a large, randomized study has examined the impact of immunosuppressive therapy for ILD secondary to systemic sclerosis, additional studies are needed to determine optimal treatment strategies for each distinct form of CTD-ILD. Finally, we review new information regarding the subgroup of patients with ILD who meet some, but not all, diagnostic criteria for a CTD. A careful and systematic approach to diagnosis in patients with ILD may reveal an unrecognized CTD or evidence of autoimmunity in those previously believed to have idiopathic ILD.
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Affiliation(s)
- Rekha Vij
- Section of Pulmonary and Critical Care, Department of Medicine, The University of Chicago, Chicago, IL.
| | - Mary E Strek
- Section of Pulmonary and Critical Care, Department of Medicine, The University of Chicago, Chicago, IL
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339
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Solomon JJ, Ryu JH, Tazelaar HD, Myers JL, Tuder R, Cool CD, Curran-Everett D, Fischer A, Swigris JJ, Brown KK. Fibrosing interstitial pneumonia predicts survival in patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD). Respir Med 2013; 107:1247-52. [PMID: 23791462 DOI: 10.1016/j.rmed.2013.05.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 05/08/2013] [Accepted: 05/13/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a systemic autoimmune disorder with a variety of extra-articular manifestations. The lung is a common target and diffuse parenchymal lung disease can appear as any of the patterns found with idiopathic interstitial pneumonia. Controversy exists as to the prognostic significance of these patterns among patients with RA-ILD. METHODS We retrospectively identified 48 patients with a diagnosis of RA-ILD confirmed by surgical lung biopsy. The pathology was reviewed by four expert pulmonary pathologists. We examined survival after stratifying on the presence or absence of fibrotic ILD, and contrasted it with a matched idiopathic pulmonary fibrosis (IPF) population. The Cox proportional hazards model was used to identify independent predictors of survival. RESULTS The majority of subjects were male smokers with physiologic restriction. A usual interstitial pneumonia (UIP)-pattern was identified in 31% of subjects. Median survival time for the entire cohort was 1360 days. Subjects with fibrotic ILD had worse survival than subjects with non-fibrotic ILD (log rank p = 0.02). There was no difference in survival between UIP-pattern RA-ILD subjects and IPF controls (log rank p = 0.94). Multivariable analysis revealed that age (hazard ratio [HR] = 1.04, p = 0.01) and fibrosis (HR = 2.1, p = 0.02) were independent predictors of mortality. CONCLUSIONS Both cellular and fibrosing ILD patterns are common among RA-ILD patients who undergo surgical lung biopsy. These patients have a shortened survival when compared to the general population and all-comers with RA. Age and the presence of a fibrosing interstitial pneumonia predict shortened survival in these patients. Survival in UIP is similar to matched IPF patients.
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Affiliation(s)
- Joshua J Solomon
- Autoimmune Lung Center and ILD Program, National Jewish Health, Denver, CO 80206, USA.
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340
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Antin-Ozerkis D, Rubinowitz A, Evans J, Homer RJ, Matthay RA. Interstitial lung disease in the connective tissue diseases. Clin Chest Med 2013; 33:123-49. [PMID: 22365251 DOI: 10.1016/j.ccm.2012.01.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The connective tissue diseases (CTDs) are inflammatory, immune-mediated disorders in which interstitial lung disease (ILD) is common and clinically important. Interstitial lung disease may be the first manifestation of a CTD in a previously healthy patient. CTD-associated ILD frequently presents with the gradual onset of cough and dyspnea, although rarely may present with fulminant respiratory failure. Infection and drug reaction should always be ruled out. A diagnosis of idiopathic ILD should never be made without a careful search for subtle evidence of underlying CTD. Treatment of CTD-ILD typically includes corticosteroids and immunosuppressive agents.
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Affiliation(s)
- Danielle Antin-Ozerkis
- Yale Interstitial Lung Disease Program, Pulmonary & Critical Care Medicine Section, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06510, USA.
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Lee H, Choi HN, Kim SH, Kim JH, Park SH, Kim SK, Hyun DS, Jung KJ, Bae J, Choe JY. Prognostic Factors of the RA Patients with ILD. JOURNAL OF RHEUMATIC DISEASES 2013. [DOI: 10.4078/jrd.2013.20.1.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hwajeong Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
- Arthritis and Autoimmunity Research Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Han Na Choi
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Si Hye Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ji Hun Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
- Arthritis and Autoimmunity Research Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Sung-Hoon Park
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
- Arthritis and Autoimmunity Research Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Seong-Kyu Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
- Arthritis and Autoimmunity Research Center, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dae Sung Hyun
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Kyung-Jae Jung
- Department of Radiology, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jisuk Bae
- Department of Preventive Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Jung-Yoon Choe
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
- Arthritis and Autoimmunity Research Center, Catholic University of Daegu School of Medicine, Daegu, Korea
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Olson AL, Brown KK, Fischer A. Connective Tissue Disease–Associated Lung Disease. Immunol Allergy Clin North Am 2012; 32:513-36. [DOI: 10.1016/j.iac.2012.09.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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345
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Maher TM. A Clinical Approach to Diffuse Parenchymal Lung Disease. Immunol Allergy Clin North Am 2012; 32:453-72. [DOI: 10.1016/j.iac.2012.08.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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346
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Gutsche M, Rosen GD, Swigris JJ. Connective Tissue Disease-associated Interstitial Lung Disease: A review. ACTA ACUST UNITED AC 2012; 1:224-232. [PMID: 23125954 DOI: 10.1007/s13665-012-0028-7] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Interstitial lung disease (ILD) is commonly encountered in patients with connective tissue diseases (CTD). Besides the lung parenchyma, the airways, pulmonary vasculature and structures of the chest wall may all be involved, depending on the type of CTD. As a result of this so-called multi-compartment involvement, airflow limitation, pulmonary hypertension, vasculitis and extrapulmonary restriction can occur alongside fibro-inflammatory parenchymal abnormalities in CTD. Rheumatoid arthritis (RA), systemic sclerosis (SSc), poly-/dermatomyositis (PM/DM), Sjögren's syndrome (SjS), systemic lupus erythematosus (SLE), and undifferentiated (UCTD) as well as mixed connective tissue disease (MCTD) can all be associated with the development of ILD. Non-specific interstitial pneumonia (NSIP) is the most commonly observed histopathological pattern in CTD-ILD, but other patterns including usual interstitial pneumonia (UIP), organizing pneumonia (OP), diffuse alveolar damage (DAD) and lymphocytic interstitial pneumonia (LIP) may occur. Although the majority of patients with CTD-ILD experience stable or slowly advancing ILD, a small yet significant group exhibits a more severe and progressive course. Randomized placebo-controlled trials evaluating the efficacy of immunomodulatory treatments have been conducted only in SSc-associated ILD. However, clinical experience suggests that a handful of immunosuppressive medications are potentially effective in a sizeable portion of patients with ILD caused by other CTDs. In this manuscript, we review the clinical characteristics and management of the most common CTD-ILDs.
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Affiliation(s)
- Markus Gutsche
- Interstitial Lung Disease Program, Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, California
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347
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Massey H, Darby M, Edey A. Thoracic complications of rheumatoid disease. Clin Radiol 2012; 68:293-301. [PMID: 22998801 DOI: 10.1016/j.crad.2012.07.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 06/11/2012] [Accepted: 07/09/2012] [Indexed: 01/15/2023]
Abstract
Rheumatoid arthritis is a relatively common multisystem disease associated with significant mortality and morbidity. Thoracic disease, both pleural and pulmonary, is a frequent extra-articular manifestation of rheumatoid arthritis and responsible for approximately 20% of rheumatoid-associated mortality. Rheumatoid disease and its associated therapies can affect all compartments of the lung inciting a range of stereotyped pathological responses and it is not infrequent for multiple disease entities to co-exist. In some instances, development of pulmonary complications may precede typical rheumatological presentation of the disease and be the first indication of an underlying connective tissue disease. The spectrum of thoracic disease related to rheumatoid arthritis is reviewed.
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Affiliation(s)
- H Massey
- Department of Radiology, Southmead Hospital, North Bristol NHS Trust, Westbury-on-Trym, Bristol, UK
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348
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Abstract
Some of the most pressing challenges associated with interstitial lung disease (ILD) are how best to define, diagnose, and treat connective tissue disease-associated ILD (CTD-ILD)--disorders with potentially substantial morbidity and mortality. In this focused review, we address aspects of prognosis for CTD-ILD and what indices might predict outcome, together with lessons that can be learnt from clinical trials of systemic sclerosis-associated ILD and idiopathic pulmonary fibrosis and how these lessons might be applied to future studies of CTD-ILD.
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Affiliation(s)
- Aryeh Fischer
- Division of Rheumatology and Interstitial Lung Disease Program, National Jewish Health, Denver, CO, USA
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349
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Antoniou KM, Margaritopoulos GA, Proklou A, Karagiannis K, Lasithiotaki I, Soufla G, Kastrinaki MC, Spandidos DA, Papadaki HA, Siafakas NM. Investigation of Telomerase/Telomeres system in Bone Marrow Mesenchymal Stem Cells derived from IPF and RA-UIP. J Inflamm (Lond) 2012; 9:27. [PMID: 22747954 PMCID: PMC3408356 DOI: 10.1186/1476-9255-9-27] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 07/02/2012] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Idiopathic Pulmonary Fibrosis and Rheumatoid Arthritis associated usual interstitial pneumonia seem to have the same poor outcome as there is not an effective treatment. The aim of the study is to explore the reparative ability of bone marrow mesenchymal stem cells by evaluating the system telomerase/telomeres and propose a novel therapeutic approach. METHODS BM-MSCs were studied in 6 IPF patients, 7 patients with RA-UIP and 6 healthy controls. We evaluated the telomere length as well as the mRNA expression of both components of telomerase (human telomerase reverse transcriptase, h-TERT and RNA template complementary to the telomeric loss DNA, h-TERC). RESULTS We found that BM-MSCs from IPF, RA-UIP cases do not present smaller telomere length than the controls (p = 0.170). There was no significant difference regarding the expression of both h-TERT and h-TERC genes between patients and healthy controls (p = 0.107 and p = 0.634 respectively). CONCLUSIONS We demonstrated same telomere length and telomerase expression in BM-MSCs of both IPF and RA-UIP which could explain similarities in pathogenesis and prognosis. Maintenance of telomere length in these cells could have future implication in cell replacement treatment with stem cells of these devastating lung disorders.
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Affiliation(s)
- Katerina M Antoniou
- Department of Thoracic Medicine, Interstitial Lung Disease Unit, University Hospital of Heraklion, Crete, Greece
- Laboratory of Cellular and Molecular Pulmonology, Medical School, University of Crete, Crete, Greece
| | - George A Margaritopoulos
- Department of Thoracic Medicine, Interstitial Lung Disease Unit, University Hospital of Heraklion, Crete, Greece
- Laboratory of Cellular and Molecular Pulmonology, Medical School, University of Crete, Crete, Greece
| | - Athanasia Proklou
- Department of Thoracic Medicine, Interstitial Lung Disease Unit, University Hospital of Heraklion, Crete, Greece
- Laboratory of Cellular and Molecular Pulmonology, Medical School, University of Crete, Crete, Greece
| | - Konstantinos Karagiannis
- Laboratory of Cellular and Molecular Pulmonology, Medical School, University of Crete, Crete, Greece
| | - Ismini Lasithiotaki
- Department of Thoracic Medicine, Interstitial Lung Disease Unit, University Hospital of Heraklion, Crete, Greece
- Laboratory of Cellular and Molecular Pulmonology, Medical School, University of Crete, Crete, Greece
| | - Giannoula Soufla
- Laboratory of Clinical Virology, Medical School, University of Crete, Heraklion, Crete, Greece
| | | | - Demetrios A Spandidos
- Laboratory of Clinical Virology, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Helen A Papadaki
- Hematopoiesis Research Laboratory, Medical School, University of Crete, Crete, Greece
| | - Nikos M Siafakas
- Department of Thoracic Medicine, Interstitial Lung Disease Unit, University Hospital of Heraklion, Crete, Greece
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350
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Malik S, Saravanan V, Kelly C. Interstitial lung disease in rheumatoid arthritis: an update on diagnosis and management. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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