Extra-articular involvement of rheumatoid arthritis in three seropositive patients in the absence of initial joint involvement

Interstitial lung disease in rheumatoid arthritis: A multidisciplinary problem in rheumatology and pulmonology

Rheumatoid arthritis (RA) is an immune-mediated rheumatic disease (IMRDs) characterized by chronic erosive arthritis and systemic damage to internal organs, leading to early disability and reduced life expectancy in patients. A particularly important place among the systemic manifestations of RA is occupied by interstitial lung diseases (ILD) – the most severe form of pulmonary pathology in RA, defined as RA-ILD, which is pathogenetically associated with risk factors (smoking, etc.) and autoimmune mechanisms underlying RA. RA-ILD is a subtype of RA characterized by a severe course and a poor prognosis и неблагоприятным прогнозом. The review presents new data regarding risk factors and biomarkers for RA-ILD; modern diagnostic capabilities based on the use of functional lung tests, high-resolution computed tomography, ultrasound examination of the lungs. Particular attention is paid to the efficacy and safety of pharmacotherapy, including methotrexate, biologics, JAK inhibitors, and antifibrotic therapy. An algorithm for the pharmacotherapy of RA-ILD has been proposed.

Anti-citrullinated Protein Antibody Generation, Pathogenesis, Clinical Application, and Prospects

Anti-citrullinated protein antibodies (ACPAs) are autoantibodies commonly observed in patients with rheumatoid arthritis (RA). Currently, most of the mechanisms of ACPA formation and bone destruction are well-understood, however, some unknown mechanisms still exist. There have been many new advances in ACPA-related clinical applications and targeted therapies. However, the existence of different ACPA subtypes is a limitation of targeted therapy. Herein, we present an overview of the process of ACPA generation, the underlying pathogenesis, and relevant clinical application and prospects.

Rituximab therapy in pericarditis associated with rheumatoid arthritis

In rheumatoid arthritis, pericarditis is commonly asymptomatic, but rarely, it progresses to a morbid complication, like cardiac tamponade or restrictive pericarditis. Current studies have indicated that conventional drugs have limited ability to reverse these lethal conditions. To date, invasive surgical measures remain the only definitive therapy for patients who are unresponsive to drugs. Recently, anti-tumor necrosis factor-α and anti-interleukin-1 antibody-based drugs have shown limited success. Consequently, given the importance of pericarditis, we need new treatment methods. Here, we describe a patient with rheumatoid arthritis and effusive pericarditis, which progressed to life-threatening cardiac tamponade. The patient responded very well to rituximab. Thus, rituximab represents a potential new therapy for this rarely treated complication of rheumatoid arthritis.

Pericarditis With Cardiac Tamponade Mimicking Yellow Nail Syndrome in a Patient With Rheumatoid Arthritis and a Paucity of Joint Symptoms

Pericarditis is a cardiac disease that commonly manifests with rheumatoid arthritis, and its complications are related to rheumatoid arthritis disease activity. The diagnosis can be complicated in patients with multiple extra-joint complications of rheumatoid arthritis. We report a case of pericarditis in an 82-year-old woman with few joint symptoms who was admitted to the hospital due to worsening edema of the lower legs and dyspnea, which progressed to cardiac tamponade. The patient presented with gradual onset of edema of both lower limbs and bilateral pleural effusion and was initially diagnosed with yellow nail syndrome. Ultimately, the patient was diagnosed with rheumatoid pericarditis due to a rapid increase in pericardial effusion. She was treated with non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine; however, the symptoms were progressive and required pericardiocentesis. After pericardiocentesis, the patient responded well to NSAIDs and colchicine, and systemic edema was relieved. This case highlights the fact that pericarditis associated with rheumatoid arthritis is not necessarily related to the severity of joint symptoms. Moreover, it can be difficult to differentiate pericarditis from multiple other diseases, such as yellow nail syndrome, in patients with rheumatoid arthritis who mainly have extra-articular symptoms.

Extra-articular involvement of rheumatoid arthritis in three seropositive patients in the absence of initial joint involvement

Introduction

Extra‐articular involvement (EAI) in rheumatoid arthritis (RA) is rare, severe and usually presents after years of joint involvement. Onset of RA as lung involvement has been published. We describe a series of three patients with strongly positive anti‐citrullinated peptide antibodies (ACPA) and rheumatoid factor (RF) positive in the absence of joint symptoms, but with significant EAI.

Methods

This is a descriptive case series of three patients evaluated in an academic medical center rheumatology clinic.

Results

A 50‐year‐old female presented with severe recurrent scleritis in the background of strongly positive ACPA, but no joint involvement. Her ocular disease responded well to rituximab. Four years later, she developed peripheral inflammatory arthritis consistent with RA. A 74‐year‐old male presented after developing recurrent steroid‐dependent serositis (pleuro‐pericarditis) and interstitial lung disease (ILD). Serology was notable for strongly positive ACPA, but no joint involvement. Serositis responded well to adalimumab. Two years after initial symptoms, he developed peripheral joint involvement after holding adalimumab. A 56‐year‐old female presented with an isolated, biopsy‐proven subcutaneous rheumatoid nodule. Subsequently, she developed pancytopenia and fatigue. She tested strongly positive for ACPA and RF. Bone marrow biopsy was negative for malignancy and she had no evidence of infection. She responded to steroids and hydroxychloroquine and had not developed joint involvement after 2 years of follow‐up.

Conclusion

EAI as an onset of RA is a complex and not easily recognized entity if typical joints involvement is not yet present. Early diagnosis may help guide specific therapy and prevent sequelae and co‐morbidities.