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Glick DR, Galvin JR, Deepak J. Complex obstructive lung disease - A diagnostic and management conundrum. Respir Med Case Rep 2020; 31:101283. [PMID: 33209580 PMCID: PMC7658492 DOI: 10.1016/j.rmcr.2020.101283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/23/2020] [Accepted: 11/02/2020] [Indexed: 10/26/2022] Open
Abstract
Rheumatoid arthritis (RA) is a common autoimmune disease most well-known for its inflammatory, destructive polyarthropathy. Extraarticular manifestations of the disease may involve the respiratory system, including interstitial lung disease, pleural disease, pulmonary vascular abnormalities, and airways disease. Smoking is highly prevalent in the RA population, and may even have a synergistic effect in disease development and progression. In the diagnosis of pulmonary disease, this presents a unique diagnostic and therapeutic challenge. We present a case of a woman in her 50s who presented for evaluation of dyspnea and was found to have obstructive lung disease. In addition to RA, she had a significant smoking history and also owned pet birds, making definitive diagnosis difficult. Ultimately, chest imaging was crucial in identifying RA-related lung disease as the root cause of her symptoms, leading to successful treatment and symptom management.
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Affiliation(s)
- Danielle R Glick
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey R Galvin
- Department of Diagnostic Radiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Janaki Deepak
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
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2
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Bessa EJC, Ribeiro FDMC, Pinheiro GDRC, Lopes AJ. Does the nitrogen single-breath washout test contribute to detecting pulmonary involvement in rheumatoid arthritis? A pilot study. BMC Res Notes 2019; 12:730. [PMID: 31699130 PMCID: PMC6836485 DOI: 10.1186/s13104-019-4767-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 10/29/2019] [Indexed: 01/23/2023] Open
Abstract
Objective There has been growing interest in studying small airway disease through measures of ventilation distribution, thanks to the resurgence of the nitrogen single-breath washout (N2SBW) test. Therefore, this study evaluated the contribution of the N2SBW test to the detection of pulmonary involvement in patients with rheumatoid arthritis (RA). Results Twenty-one patients with RA underwent clinical evaluation, pulmonary function tests (PFTs), including the N2SBW test, and computed tomography (CT). The main tomographic findings were air trapping and bronchiectasis (57.1% and 23.8% of cases, respectively). According to the phase III slope of the N2SBW (phase III slope), 11 and 10 patients had values < 120% predicted and > 120% predicted, respectively. Five patients with limited involvement on CT had a phase III slope > 120%. The residual volume/total lung capacity ratio was significantly different between patients with phase III slopes < 120% and > 120% (P = 0.024). Additionally, rheumatoid factor positivity was higher in patients with a phase III slope > 120% (P = 0.021). In patients with RA and airway disease on CT, the N2SBW test detects inhomogeneity in the ventilation distribution in approximately half of the cases, even in those with normal conventional PFT results.
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Affiliation(s)
- Elizabeth Jauhar Cardoso Bessa
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro (UERJ), Boulevard 28 de Setembro, 77, Vila Isabel, Rio de Janeiro, 20551-030, Brazil
| | | | - Geraldo da Rocha Castelar Pinheiro
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro (UERJ), Boulevard 28 de Setembro, 77, Vila Isabel, Rio de Janeiro, 20551-030, Brazil
| | - Agnaldo José Lopes
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro (UERJ), Boulevard 28 de Setembro, 77, Vila Isabel, Rio de Janeiro, 20551-030, Brazil. .,Rehabilitation Sciences Postgraduate Programme, Augusto Motta University Centre (UNISUAM), Rua Dona Isabel, 94, Bonsucesso, Rio de Janeiro, 21032-060, Brazil. .,, Rua Araguaia, 1266, Bloco 1/405, Freguesia/Jacarepaguá, Rio de Janeiro, RJ, 22745-271, Brazil.
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Ujino M, Miyoshi S, Sugimoto N, Arai H, Ota Y, Sasajima Y, Kawamura M, Nagase H, Yamaguchi M, Ohta K. Methotrexate-associated Lymphoproliferative Disorder: A Rare Differential Diagnosis of Wheezes. Intern Med 2019; 58:1759-1764. [PMID: 30713294 PMCID: PMC6630116 DOI: 10.2169/internalmedicine.2080-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 70-year-old woman was admitted for the evaluation of wheezes and a nodular lesion in the left lung field. She had been diagnosed with rheumatoid arthritis at 45 years of age and was continuously treated with methotrexate (MTX) at 8 mg/week. Bronchoscopic aspiration histology of a hilar lymph node suggested a lymphoproliferative disorder (LPD). After discontinuation of MTX, the lung nodule and wheezes disappeared. Although wheezes are not a usual manifestation of LPD, her clinical course clearly demonstrated an obvious relationship between LPD-induced airway narrowing and wheezes.
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Affiliation(s)
- Mariko Ujino
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Japan
| | - Shoki Miyoshi
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Japan
| | - Naoya Sugimoto
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Japan
| | - Hidenori Arai
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Japan
| | - Yasunori Ota
- Department of Pathology, Teikyo University School of Medicine, Japan
- Department of Pathology, Teikyo University Hospital, Japan
| | - Yuko Sasajima
- Department of Pathology, Teikyo University School of Medicine, Japan
- Department of Pathology, Teikyo University Hospital, Japan
| | | | - Hiroyuki Nagase
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Japan
| | - Masao Yamaguchi
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Japan
| | - Ken Ohta
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Japan
- JATA Fukujuji Hospital, Japan
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Interstitial Pneumonia with Autoimmune Features: Overview of proposed criteria and recent cohort characterization. ACTA ACUST UNITED AC 2017; 24:191-196. [PMID: 29276366 DOI: 10.1097/cpm.0000000000000227] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The accurate diagnosis of interstitial lung disease (ILD) is essential for optimal prognostication and management. While connective tissue disease (CTD) is among the most common causes of ILD, some patients have features suggestive of autoimmunity without meeting criteria for a specific CTD. To help define and study this disease entity more uniformly, a 2015 research statement proposed consensus-based criteria and coined the term "interstitial pneumonia with autoimmune features" (IPAF). In this review, we summarize and compare previously proposed criteria to characterize these patients, provide an overview of the IPAF criteria and highlight recent investigations aimed at characterizing IPAF cohorts. We then call attention to questions that have arisen with the application of the IPAF criteria and discuss future areas of study.
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Association of Single Nucleotide Polymorphisms of PADI4 and HLA-DRB1 Alleles with Susceptibility to Rheumatoid Arthritis-Related Lung Diseases. Lung 2016; 194:745-53. [DOI: 10.1007/s00408-016-9916-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 06/19/2016] [Indexed: 01/09/2023]
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Sokai R, Ito S, Iwano S, Uchida A, Aso H, Kondo M, Ishiguro N, Kojima T, Hasegawa Y. Respiratory mechanics measured by forced oscillation technique in rheumatoid arthritis-related pulmonary abnormalities: frequency-dependence, heterogeneity and effects of smoking. SPRINGERPLUS 2016; 5:335. [PMID: 27064652 PMCID: PMC4792822 DOI: 10.1186/s40064-016-1952-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 02/29/2016] [Indexed: 11/10/2022]
Abstract
Rheumatoid arthritis (RA)-related pulmonary disorders specifically airway abnormalities and interstitial pneumonia (IP) are important extra-articular manifestations. The forced oscillation technique (FOT) is a useful method to assess respiratory impedance, respiratory resistance (Rrs) and reactance (Xrs), at different oscillatory frequencies during tidal breathing. The aim of this study was to characterize the respiratory mechanics of patients with RA and to relate them to parameters of the pulmonary function test and findings of chest CT images. Respiratory impedance of RA patients (n = 69) was measured as a function of frequency from 4 to 36 Hz using the FOT device and compared with that of healthy subjects (n = 10). Data were retrospectively reviewed. Patients were female-dominant (60.9 %) and 95.7 % had abnormal CT findings including airway and parenchymal abnormalities. Thirty-seven of 69 patients (53.6 %) were smokers. Rrs was significantly frequency-dependent in RA patients but not in the healthy subjects. Xrs were significantly frequency-dependent in both RA and healthy groups. Rrs was significantly higher during an expiratory phase in both RA and healthy groups. Xrs was significantly lower (more negative) during an expiratory phase than that during an inspiratory phase in RA patients but not in healthy subjects. Xrs of the RA group was significantly more negative than that of the normal control. There was no difference in impedance parameters between the airway lesion dominant (n = 27) and IP dominant groups (n = 23) in the RA group. The impedance parameters of the RA group significantly correlated with most parameters of the pulmonary function test. In pulmonary function test results, % of the predicted value for forced expiratory flow from 25 to 75 % of forced vital capacity was significantly lower and % of the predicted value for diffusing capacity of the lung for carbon monoxide was higher in the airway lesion dominant group than those in the IP dominant group. Krebs von den Lungen-6, a serum indicator of IP, was significantly higher in the IP group than that in the airway lesion dominant group. Taken together, the impedance results reflect abnormalities in pulmonary functions and structures in patients with RA.
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Affiliation(s)
- Risa Sokai
- Department of Respiratory Medicine, Nagoya University School of Medicine, Nagoya, 466-8550 Japan
| | - Satoru Ito
- Department of Respiratory Medicine, Nagoya University School of Medicine, Nagoya, 466-8550 Japan
| | - Shingo Iwano
- Department of Radiology, Nagoya University School of Medicine, Nagoya, 466-8550 Japan
| | - Akemi Uchida
- Department of Clinical Laboratory, Nagoya University School of Medicine, Nagoya, 466-8550 Japan
| | - Hiromichi Aso
- Department of Respiratory Medicine, Nagoya University School of Medicine, Nagoya, 466-8550 Japan
| | - Masashi Kondo
- Department of Respiratory Medicine, Nagoya University School of Medicine, Nagoya, 466-8550 Japan
| | - Naoki Ishiguro
- Department of Orthopedic Surgery and Rheumatology, Nagoya University School of Medicine, Nagoya, 466-8550 Japan
| | - Toshihisa Kojima
- Department of Orthopedic Surgery and Rheumatology, Nagoya University School of Medicine, Nagoya, 466-8550 Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University School of Medicine, Nagoya, 466-8550 Japan
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Abstract
Comprehensive, up-to-date review of RA-associated lung diseases including pathogenesis and managementhttp://ow.ly/FBaNZ
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Affiliation(s)
- Megan Shaw
- Division of Rheumatology, UW Medical Centre, University of Washington, Seattle, WA, USA
| | - Bridget F Collins
- Division of Pulmonary and Critical Care Medicine, UW Medical Centre, University of Washington, Seattle, WA, USA
| | - Lawrence A Ho
- Division of Pulmonary and Critical Care Medicine, UW Medical Centre, University of Washington, Seattle, WA, USA
| | - Ganesh Raghu
- Division of Pulmonary and Critical Care Medicine, UW Medical Centre, University of Washington, Seattle, WA, USA
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Visual Assessment of Chest Computed Tomography Findings in Anti-cyclic Citrullinated Peptide Antibody Positive Rheumatoid Arthritis: Is it Associated with Airway Abnormalities? Lung 2015; 194:97-105. [PMID: 26608346 DOI: 10.1007/s00408-015-9828-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Accepted: 11/20/2015] [Indexed: 12/31/2022]
Abstract
INTRODUCTION We aimed to evaluate the association between specific anti-cyclic citrullinated peptide antibody (ACCPA) and pulmonary abnormalities in rheumatoid arthritis (RA) subjects. METHODS Computed tomography (CT) images of 83 subjects with RA were evaluated in a blind fashion. Enrolled subjects underwent autoantibody testing to determinate titer of ACCPA and rheumatoid factor, and pulmonary function testing. Visual CT assessment included lobar analysis for extent of semi-quantitative total interstitial lung disease score (ILDS) and each airway abnormality score (bronchiectasis, bronchial wall thickening, centrilobular nodules, and expiratory air trapping). Correlation tests, and simple and multiple regression analyses were performed to determine the relationship between the visual CT abnormalities, physiologic parameters, and autoantibody titers. RESULTS ACCPA-positive subjects had a greater extent and higher prevalence of small airway abnormalities including centrilobular nodules and air trapping compared to ACCPA-negative subjects (all p < 0.05). Bronchiectasis and bronchial wall thickening correlated with the ratio of forced expiratory volume in 1 s and forced vital capacity (FVC) (r = -0.236 and r = -0.329, all p < 0.05), and ILDS correlated with FVC and the diffusing capacity of the lung for carbon monoxide (r = -0.218 and r = -0.366, all p < 0.05). Bronchial wall thickening and air trapping correlated with ACCPA titers (r = 0.235 and r = 0.264, all p < 0.05). Air trapping and bronchial wall thickening were significantly associated with ACCPA titers. CONCLUSION In ACCPA (+) RA, visual CT assessment of large and small airways beyond RA-ILD, which is attributable to RA-related autoimmunity, can provide valuable information regarding airway abnormalities, regardless of the patients' physiologic airflow limitations.
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Mori S, Koga Y, Sugimoto M. Organizing Pneumonia in Rheumatoid Arthritis Patients: A Case-Based Review. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:69-80. [PMID: 26543387 PMCID: PMC4624096 DOI: 10.4137/ccrpm.s23327] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 09/08/2015] [Accepted: 09/14/2015] [Indexed: 12/29/2022]
Abstract
We treated 21 patients with organizing pneumonia (OP) associated with rheumatoid arthritis (RA) or related to biological disease-modifying antirheumatic drugs (DMARDs) at our institution between 2006 and 2014. Among these cases, 3 (14.3%) preceded articular symptoms of RA, 4 (19.0%) developed simultaneously with RA onset, and 14 (66.7%) occurred during follow-up periods for RA. In the case of OP preceding RA, increased levels of anti-cyclic citrullinated peptide antibodies and rheumatoid factor were observed at the OP onset. RA disease activity was related to the development of OP in the simultaneous cases. In the cases of OP developing after RA diagnosis, 10 of 14 patients had maintained low disease activity with biological DMARD therapy at the OP onset, and among them, 6 patients developed OP within the first year of this therapy. In the remaining four patients, RA activity was not controlled at the OP onset. All patients responded well to systemic steroid therapy, but two patients suffered from relapses of articular and pulmonary symptoms upon steroid tapering. In most of the RA patients, DMARD therapy was introduced or restarted during the steroid tapering. We successfully restarted a biological DMARD that had not been previously used for patients whose RA would otherwise have been difficult to control. In this study, we also perform a review of the literature on RA-associated or biological DMARD-related OP and discuss the pathogenesis and management of OP occurring in RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
| | - Yukinori Koga
- Department of Radiology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
| | - Mineharu Sugimoto
- Division of Respiratory Medicine, Department of Medicine, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
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Mori S. Management of Rheumatoid Arthritis Patients with Interstitial Lung Disease: Safety of Biological Antirheumatic Drugs and Assessment of Pulmonary Fibrosis. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:41-9. [PMID: 26401101 PMCID: PMC4564070 DOI: 10.4137/ccrpm.s23288] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/04/2015] [Accepted: 08/06/2015] [Indexed: 02/07/2023]
Abstract
Interstitial lung disease (ILD) is one of the major causes of morbidity and mortality of patients with rheumatoid arthritis (RA). Accompanying the increased number of reports on the development or exacerbation of ILD in RA patients following therapy with biological disease-modifying antirheumatic drugs (DMARDs), RA-associated ILD (RA-ILD) has aroused renewed interest. Although such cases have been reported mainly in association with the use of tumor necrosis factor inhibitors, the use of other biological DMARDs has also become a matter of concern. Nevertheless, it is difficult to establish a causative relationship between the use of biological DMARDs and either the development or exacerbation of ILD. Such pulmonary complications may occur in the natural course of RA regardless of the use of biological DMARDs. Since rheumatologists currently aim to achieve remission in RA patients, the administration of biological DMARDs is increasing, even for those with RA-ILD. However, there are no reliable, evidence-based guidelines for deciding whether biological DMARDs can be safely introduced and continued in RA-ILD patients. A standardized staging system for pulmonary conditions of RA-ILD patients is needed when making therapeutic decisions at baseline and monitoring during biological DMARD therapy. Based on the available information regarding the safety of biological DMARDs and the predictive factors for a worse prognosis, this review discusses candidate parameters for risk evaluation of ILD in RA patients who are scheduled to receive biological antirheumatic therapy.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
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11
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Mori S, Sugimoto M. Pneumocystis jirovecii Pneumonia in Rheumatoid Arthritis Patients: Risks and Prophylaxis Recommendations. CLINICAL MEDICINE INSIGHTS-CIRCULATORY RESPIRATORY AND PULMONARY MEDICINE 2015; 9:29-40. [PMID: 26396551 PMCID: PMC4562607 DOI: 10.4137/ccrpm.s23286] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/03/2015] [Accepted: 08/06/2015] [Indexed: 01/05/2023]
Abstract
Pneumocystis jirovecii infection causes fulminant interstitial pneumonia (Pneumocystis pneumonia, PCP) in patients with rheumatoid arthritis (RA) who are receiving biological and/or nonbiological antirheumatic drugs. Recently, we encountered a PCP outbreak among RA outpatients at our institution. Hospital-acquired, person-to-person transmission appears to be the most likely mode of this cluster of P. jirovecii infection. Carriage of P. jirovecii seems a time-limited phenomenon in immunocompetent hosts, but in RA patients receiving antirheumatic therapy, clearance of this organism from the lungs is delayed. Carriers among RA patients can serve as sources and reservoirs of P. jirovecii infection for other susceptible patients in outpatient facilities. Development of PCP is a matter of time in such carriers. Considering the poor survival rates of PCP cases, prophylactic antibiotics should be considered for RA patients who are scheduled to receive antirheumatic therapy. Once a new case of PCP occurs, we should take prompt action not only to treat the PCP patient but also to prevent other patients from becoming new carriers of P. jirovecii. Short-term prophylaxis with trimethoprim-sulfamethoxazole is effective in controlling P. jirovecii infection and preventing future outbreaks of PCP among RA patients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Diseases, NHO Kumamoto Saishunsou National Hospital, Kumamoto, Japan
| | - Mineharu Sugimoto
- Division of Respiratory Medicine, Department of Medicine, Social Insurance Omuta Tenryo Hospital, Fukuoka, Japan
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Perry E, Kelly C, Eggleton P, De Soyza A, Hutchinson D. The lung in ACPA-positive rheumatoid arthritis: an initiating site of injury? Rheumatology (Oxford) 2014; 53:1940-50. [DOI: 10.1093/rheumatology/keu195] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Fernández Pérez ER, Krishnamoorthy M, Brown KK, Huie TJ, Fischer A, Solomon JJ, Meehan RT, Olson AL, Achcar RD, Swigris JJ. FEV1 over time in patients with connective tissue disease-related bronchiolitis. Respir Med 2013; 107:883-9. [PMID: 23582575 DOI: 10.1016/j.rmed.2013.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 02/25/2013] [Accepted: 02/28/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Fibrosis or inflammation of the bronchioles is a well-known manifestation of connective tissue disease (CTD). However, the natural history of CTD-related bronchiolitis is largely unknown. METHODS We analyzed consecutive patients evaluated at National Jewish Health (Denver, CO) from 1998 to 2008 with CTD and surgical lung biopsy-confirmed bronchiolitis. Linear mixed effects models were used to estimate the longitudinal postbronchodilator FEV1 %predicted (%pred) course and differences between subjects with or without constrictive bronchiolitis (CB). RESULTS Of 28 subjects with a mean age of 53 ± 9 years, fourteen (50%) had CB. The most common CTD diagnosis was rheumatoid arthritis (n = 14; 50%). There were no significant differences in demographics, smoking status, underlying CTD diagnoses, 6-min walk distance, dyspnea score or drug therapy between subjects with CB and those with cellular bronchiolitis. Three subjects with CB (11%) and four with cellular bronchiolitis (14%) died. Compared with subjects with CB, those with cellular bronchiolitis had higher mean FEV1 %pred at all times. There were no significant differences in FEV1 %pred slope within- or between-groups (CB vs. cellular bronchiolitis) preceding surgical lung biopsy or afterward. CONCLUSION Subjects with CTD-related CB had lower FEV1 %pred values than those with CTD-related cellular bronchiolitis at all time points, but FEV1 %pred remained stable over time in both groups regardless of therapy received.
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Affiliation(s)
- Evans R Fernández Pérez
- Autoimmune Lung Center and Interstitial Lung Disease Program, National Jewish Health, Denver, CO 80206, USA.
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Zohal MA, Yazdi Z, Ghaemi AR, Abbasi M. Small airways involvement in patients with rheumatoid arthritis. Glob J Health Sci 2012; 5:166-70. [PMID: 23445704 PMCID: PMC4776798 DOI: 10.5539/gjhs.v5n2p166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 12/18/2012] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES One of the common causes of morbidity in patients with RA is pulmonary involvement. Some studies have shown that the possible abnormal results of pulmonary function tests in rheumatoid disease are higher than usual. We aimed to evaluate the prevalence of spirometric abnormalities in patients with RA. MATERIALS & METHODS This case-control study was conducted on 99 patients with RA who referred to a rheumatology clinic in Qazvin, northwest Iran. Sixty five age- and sex-matched healthy controls were recruited as well. History taking, physical examination, laboratory tests and spirometry were performed for the participants. RA severity was assessed according to Disease Activity Score 28 (DAS28). The data were processed using SPSS software version 16. Chi square and student's t test and multiple logistic regressions were used as appropriated. RESULTS The mean (±SD) age of the patients was 46 (±10.5) years. The mean (±SD) duration of disease was 4.8 (±5.4) years, and the mean (±SD) DAS28 was 2.5 (±1.1). Dyspnea was the most common respiratory complaint (6.1%). Three (3%) patients had mild restrictive, 2 (2%) patients mild obstructive, and one (1%) patient moderate obstructive diseases. In the control group, only one participant had mild restrictive pulmonary disease (P<0.05). A significant decrease of FEF25 [OR=3.2; 95%CI (1.9-4.5)], FEF50 [OR=2.5; 95% CI (1.7-3.1)], FEF75 [OR=2.3; 95% CI (1.4-2.7)] and FEF25-75 [OR=2.7; 95% CI (1.7-3.5)] was observed in patients compared with the control group. We found no correlation between the patients' age, duration and severity of the disease, and laboratory tests with spirometric indices. CONCLUSION It is recommended that patients with RA be visited on a regular basis and PFT be done for them for the early diagnosis of pulmonary involvement.
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Affiliation(s)
- Mohammad Ali Zohal
- Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Zohreh Yazdi
- Occupational Medicine Specialist, Qazvin University of Medical Sciences, Qazvin, Iran
| | | | - Mahnaz Abbasi
- Metabolic Diseases Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
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Mori S, Sugimoto M. Pneumocystis jirovecii infection: an emerging threat to patients with rheumatoid arthritis. Rheumatology (Oxford) 2012; 51:2120-30. [PMID: 23001613 PMCID: PMC3510430 DOI: 10.1093/rheumatology/kes244] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 07/31/2012] [Indexed: 01/15/2023] Open
Abstract
Accompanying the increased use of biologic and non-biologic antirheumatic agents, patients with RA have been exposed to an increased risk of Pneumocystis jirovecii infection, which causes acute fulminant P. jirovecii pneumonia (PCP). Mortality in this population is higher than in HIV-infected individuals. Several guidelines and recommendations for HIV-infected individuals are available; however, such guidelines for RA patients remain less clear. Between 2006 and 2008 we encountered a clustering event of P. jirovecii infection among RA outpatients. Through our experience with this outbreak and a review of the recent medical literature regarding asymptomatic colonization and its clinical significance, transmission modes of infection and prophylaxis of PCP, we have learned the following lessons: PCP outbreaks among RA patients can occur through person-to-person transmission in outpatient facilities; asymptomatic carriers serve as reservoirs and sources of infection; and short-term prophylaxis for eradication of P. jirovecii is effective in controlling PCP outbreaks among RA outpatients.
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Disease, NHO Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto 861-1196, Japan.
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Tillie-Leblond I, Crestani B, Perez T, Nunes H. [The distal airways in systemic disease]. Rev Mal Respir 2012; 29:1254-63. [PMID: 23228682 DOI: 10.1016/j.rmr.2012.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/07/2012] [Indexed: 01/06/2023]
Abstract
The association of inflammatory involvement of the distal airways or bronchiolitis and systemic diseases is essentially observed in Sjögren's syndrome, rheumatoid arthritis and chronic inflammatory bowel disease. Bronchiolitis may be mainly cellular in nature, often involving lympho-monocytic cells, and sometimes associated with lymphoid follicles, as in Sjögren's syndrome. It may also, particularly in rheumatoid arthritis, be constrictive, with peribronchiolar fibrosis. This type is associated with a worse prognosis, with possible progression to chronic respiratory insufficiency. The diagnosis of bronchiolitis should be suspected in any atypical form of asthma, or recurrent "bronchitis", and it is essential to look for extrarespiratory symptoms and auto-antibodies to establish the diagnose of systemic disease. The CT appearances coupled with the evaluation of pulmonary function parameters usually lead to the diagnosis. In severe and/or rapidly progressive cases treatment-combining corticosteroids with immunosuppressive drugs may be prescribed, but often with disappointing results. In these cases, lung transplantation should be considered in young patients.
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Affiliation(s)
- I Tillie-Leblond
- Service de Pneumologie et D'immuno-Allergologie, Hôpital Calmette, Institut Pasteur de Lille, Université de Lille II et CHRU, France.
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Abstract
Bronchiolitis is a disease of the small airways accompanied by progressive and often irreversible airflow obstruction. Bronchiolitis can have several causes such as infection, toxic exposure, collagen vascular disease, post lung and stem cell transplant, and idiopathic etiology. Symptoms of cough and sputum production are often mistaken for chronic obstructive pulmonary disease or asthma, leading to a delay in diagnosis. Unfortunately, many types of bronchiolitis do not improve with therapy. Bronchiolitis following lung and stem cell transplant are the most common types seen in adults, and provide important insights into its pathogenesis.
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Affiliation(s)
- Brian T Garibaldi
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 5501 Hopkins Bayview Circle, Baltimore, MD 21224, USA
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Faria ACD, Barbosa WR, Lopes AJ, Pinheiro GDRC, Melo PLD. Contrasting diagnosis performance of forced oscillation and spirometry in patients with rheumatoid arthritis and respiratory symptoms. Clinics (Sao Paulo) 2012; 67:987-94. [PMID: 23018292 PMCID: PMC3438257 DOI: 10.6061/clinics/2012(09)01] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Accepted: 04/01/2012] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Pulmonary involvement in rheumatoid arthritis is directly responsible for 10% to 20% of all mortality. The best way to improve the prognosis is early detection and treatment. The forced oscillation technique is easy to perform and offers a detailed exam, which may be helpful in the early detection of respiratory changes. This study was undertaken to (1) evaluate the clinical potential of the forced oscillation technique in the detection of early respiratory alterations in rheumatoid arthritis patients with respiratory complaints and (2) to compare the sensitivity of forced oscillation technique and spirometric parameters. METHODS A total of 40 individuals were analyzed: 20 healthy and 20 with rheumatoid arthritis (90% with respiratory complaints). The clinical usefulness of the parameters was evaluated by investigating the sensibility, the specificity and the area under the receiver operating characteristic curve. ClinicalTrials.gov: NCT01641705. RESULTS The early adverse respiratory effects of rheumatoid arthritis were adequately detected by the forced oscillation technique parameters, and a high accuracy for clinical use was obtained (AUC.0.9, Se = 80%, Sp = 95%). The use of spirometric parameters did not obtain an appropriate accuracy for clinical use. The diagnostic performance of the forced oscillation technique parameters was significantly higher than that of spirometry. CONCLUSIONS The results of the present study provide substantial evidence that the forced oscillation technique can contribute to the easy identification of initial respiratory abnormalities in rheumatoid arthritis patients that are not detectable by spirometric exams. Therefore, we believe that the forced oscillation technique can be used as a complementary exam that may help to improve the treatment of breathing disorders in rheumatoid arthritis patients.
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Affiliation(s)
- Alvaro Camilo Dias Faria
- Biomedical Instrumentation Laboratory, Institute of Biology and Faculty of Engineering, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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Mori S, Tokuda H, Sakai F, Johkoh T, Mimori A, Nishimoto N, Tasaka S, Hatta K, Matsushima H, Kaise S, Kaneko A, Makino S, Minota S, Yamada T, Akagawa S, Kurashima A. Radiological features and therapeutic responses of pulmonary nontuberculous mycobacterial disease in rheumatoid arthritis patients receiving biological agents: a retrospective multicenter study in Japan. Mod Rheumatol 2011; 22:727-37. [PMID: 22207481 PMCID: PMC3440561 DOI: 10.1007/s10165-011-0577-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 12/08/2011] [Indexed: 11/30/2022]
Abstract
Objective This study was performed to evaluate the radiological features of and therapeutic responses to pulmonary disease caused by nontuberculous mycobacteria (NTM) in the setting of biological therapy for rheumatoid arthritis (RA). Methods We conducted a retrospective chart review of 13 patients from multiple centers who had developed pulmonary NTM disease during biological therapy for RA, including infliximab, etanercept, adalimumab, and tocilizumab. Results Most cases were asymptomatic or resulted in only common-cold-like symptoms. Abnormalities in computed tomography (CT) imaging were protean and frequently overlapped. The most predominant pattern was nodular/bronchiectatic disease (six cases), followed by alveolar infiltrate (three cases), cavitary disease (two cases), and pulmonary nodules (two cases). In most cases, pulmonary NTM disease had spread from a preexisting lesion; in particular, bronchial/bronchiolar abnormalities. In three cases, one or more nodular lesions with or without calcification were a focus of disease. Following the discontinuation of biological agents, most patients responded to anti-NTM therapy. Two patients showed no exacerbation in the absence of any anti-NTM therapy. In one patient, restarting tocilizumab therapy while continuing to receive adequate anti-NTM therapy produced a favorable outcome. In two other patients with a previous history of pulmonary NTM disease, introducing biological therapy led to recurrence, but anti-NTM therapy was effective in these patients. Conclusion CT abnormalities of pulmonary NTM disease in RA patients receiving biological therapy were variable, but were not unique to this clinical setting. NTM disease can spread from preexisting structural abnormalities, even if they are minute. Contrary to our expectations, the therapeutic outcomes of pulmonary NTM disease were favorable in these patients.
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MESH Headings
- Adalimumab
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal, Humanized/adverse effects
- Antirheumatic Agents/adverse effects
- Arthritis, Rheumatoid/complications
- Arthritis, Rheumatoid/diagnostic imaging
- Arthritis, Rheumatoid/drug therapy
- Etanercept
- Female
- Humans
- Immunoglobulin G/adverse effects
- Infliximab
- Male
- Middle Aged
- Mycobacterium Infections, Nontuberculous/chemically induced
- Mycobacterium Infections, Nontuberculous/complications
- Mycobacterium Infections, Nontuberculous/diagnostic imaging
- Radiography, Thoracic
- Receptors, Tumor Necrosis Factor
- Retrospective Studies
- Tomography, X-Ray Computed
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Affiliation(s)
- Shunsuke Mori
- Department of Rheumatology, Clinical Research Center for Rheumatic Disease, NHO Kumamoto Saishunsou National Hospital, 2659 Suya, Kohshi, Kumamoto 861-1196, Japan.
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