Pulmonary manifestations of rheumatic disease

An interesting finding of multiple calcified pulmonary nodules in a patient with rheumatoid arthritis

Calcified pulmonary (lung parenchymal) densities can occur in a number of conditions. A patient with rheumatoid arthritis presented with new right lung base nodules and left long base soft-tissue densities on his chest X-ray. These findings did not exist on his chest X-ray performed 2 years earlier. A subsequent thoracic CT scan showed multiple pleural-based irregular nodules of soft-tissue density that were partially calcified. There was also mediastinal and hilar lymphadenopathy. Following a discussion at the respiratory multidisciplinary team meeting, a CT-guided nodal biopsy was performed that showed necrotic lung tissue with palisaded histiocytes and fibrosis with chronic inflammation. No vasculitis or granulomata were seen and no there was evidence of malignancy. Appearances were consistent with a rheumatoid nodule. No mycobacteria or fungi were seen on Ziehl–Neelsen, Wade–Fite or periodic acid–Schiff stains. We concluded that this patient had unusual calcified rheumatoid lung nodules. Previously, calcified pulmonary nodules have been reported in the setting of Caplan’s syndrome in miners.

Management of therapy-resistant rheumatoid arthritis

During the last two decades, newly introduced therapeutic strategies have resulted in satisfactory modification of the disease course in the majority of the patients with rheumatoid arthritis (RA). Nevertheless, a definite number of RA patients remain therapy-resistant, and for this group more aggressive treatment may be required for preventing permanent disability and progressive joint damage necessitating surgical procedures. Therefore, management of therapy-resistant RA is one of the major challenges in modern rheumatology. RA patients who have not responded to conventional disease-modifying antirheumatic drug (DMARD) therapy are defined as refractory RA patients. However, a uniform description or definition for 'refractory' RA does not appear to be available. In this article we will deal with, and discuss, the term 'refractory RA' based on a MEDLINE database search using this term, currently available therapeutic options, data on therapy-resistant RA patients from an inception cohort of RA patients attending the Nijmegen University Hospital, management of extra-articular manifestations and future management strategies.

[Pleural effusion as initial presentation of rheumatoid arthritis. Cytological diagnosis]

A 24-year-old woman with an unremarkable history presented with a large right-sided pleural effusion. Analysis of the pleural fluid showed a sterile exudate with a low sugar level. Complementary analyses were unable to pinpoint the etiology. The effusion was drained and the patient was released with no specific diagnosis. Nine months later the effusion recurred and the initial laboratory analyses were the same. Pleural fluid cytology revealed the presence of an amorphous necrotic background and non-small cells with multiple nuclei, two signs that constitute part of the pathognomonic triad of rheumatoid pleural effusions, the third characteristic benign fusiform histocytes. The biochemical characteristics of the pleural fluid thus suggested rheumatoid pleural effusion, and cytology confirmed the diagnosis. Corticoid therapy effected spectacular recovery, but when the dose was reduced, rheumatoid symptoms presented in the joints. Rheumatoid arthritis should be considered as a possible explanation for unexplained pleural effusion. Cytology must be used for diagnosis.