Thoracic manifestations of collagen vascular diseases

Diagnostic Approach to Interstitial Lung Diseases Associated with Connective Tissue Diseases

Interstitial lung disorders are a group of respiratory diseases characterized by interstitial compartment infiltration, varying degrees of infiltration, and fibrosis, with or without small airway involvement. Although some are idiopathic (e.g., idiopathic pulmonary fibrosis, idiopathic interstitial pneumonias, and sarcoidosis), the great majority have an underlying etiology, such as systemic autoimmune rheumatic disease (SARD, also called Connective Tissue Diseases or CTD), inhalational exposure to organic matter, medications, and rarely, genetic disorders. This review focuses on diagnostic approaches in interstitial lung diseases associated with SARDs. To make an accurate diagnosis, a multidisciplinary, personalized approach is required, with input from various specialties, including pulmonary, rheumatology, radiology, and pathology, to reach a consensus. In a minority of patients, a definitive diagnosis cannot be established. Their clinical presentations and prognosis can be variable even within subsets of SARDs.

CT evaluation of interstitial lung disease related to systemic sclerosis: visual versus automated assessment. A systematic review

AIM

To identify similarities and differences between visual (VA) and automated assessment (AA) of systemic sclerosis-related interstitial lung disease (SSc-ILD) at chest computed tomography (CT) in terms of clinical applicability.

MATERIALS AND METHODS

Medline, Embase, and Web of Science were searched to identify all studies investigating VA and AA for SSc-ILD assessment, from inception to 31 July 2022. Exclusion criteria were manuscripts not in English, absence of full-text, reviews, diseases other than ILD in SSc, CT not analysed with both VA and AA, VA and AA not adopted for the same purpose or not compared, overlap syndromes, SSc-ILD data not extractable, and studies with <10 patients.

RESULTS

Ten full-text studies (804 patients) were included. The most adopted VAs were the Warrick or Goh score (four studies each), while densitometry (eight studies) or lung texture analysis (LTA, two studies) were utilised as AAs. The main field of investigation was the correlation with baseline pulmonary function tests (PFT, six studies). Warrick VA showed lower correlations compared to densitometry, while Goh VA demonstrated more heterogeneous results. Compared to LTA, Goh VA obtained lower correlations with lung volumes but similar or stronger coefficients with alveolar diffusibility.

CONCLUSIONS

VA and AA may show heterogeneous results comparing their correlations with PFT, probably depending on the specific analysis adopted for each method. More data are needed on VA versus LTA. Comparisons between VA and AA regarding correlation with PFT follow-up and as prognostic elements, or for disease monitoring, are lacking. AAs in progressive fibrosis diagnosis remain to be tested.

The Role of Radiology in Multidisciplinary Discussion of Patients With Interstitial Lung Diseases

Radiologists fulfill a vital role in the multidisciplinary care provided to patients with interstitial lung diseases and other diffuse parenchymal lung disorders. The diagnosis of interstitial lung diseases hinges on the consensus of clinical, radiology, and pathology medical subspecialists, but additional expertise from rheumatology, immunology, or hematology can be invaluable. The thin-section computed tomography (CT) features of lung involvement informs the diagnostic approach. Radiologists should be familiar with radiologic methods (including inspiratory/expiratory and prone imaging) and be well versed in the recognition of the CT features of fibrosis, assessment of the overall pattern of lung involvement, and classification according to the latest guidelines. We present a case-based review that highlights examples wherein CT features and subspecialist radiologist interpretation informed the multidisciplinary team consensus diagnosis and care pathways.

Pulmonary Alveolar Proteinosis-associated Pulmonary Fibrosis: Evolutional Changes and Radiologic-Pathologic Correlation

Pulmonary alveolar proteinosis (PAP) is a rare disease with frequently favorable outcomes. In a minority of patients with primary or secondary PAP, the disease course may be complicated by pulmonary fibrosis (PF) despite appropriate management. Imaging and histopathologic manifestations of uncomplicated PAP are well-known. In contrast, radiologic-pathologic descriptions of PAP-associated PF (PAP-PF) are limited. The current manuscript presents three cases of PAP-PF, each with serial high-resolution CT imaging demonstrating the longitudinal progression of this unusual complication, with concordant pathologic findings in two patients. Much remains to be known regarding adverse prognostic factors contributing to PAP-PF. Early recognition of radiologic-pathologic manifestations would allow timely diagnosis and management optimization. Keywords: CT, Lung, Inflammation, Pathology © RSNA, 2023.

Diagnosing lung involvement in inflammatory rheumatic diseases-Where do we currently stand?

Lung involvement is the most common and serious organ manifestation in patients with inflammatory rheumatic disease (IRD). The type of pulmonary involvement can differ, but the most frequent is interstitial lung disease (ILD). The clinical manifestations of IRD-ILD and severity can vary from subclinical abnormality to dyspnea, respiratory failure, and death. Consequently, early detection is of significant importance. Pulmonary function test (PFT) including diffusing capacity of the lungs for carbon monoxide (DLCO), and forced vital capacity (FVC) as well as high-resolution computed tomography (HRCT) are the standard tools for screening and monitoring of ILD in IRD-patients. Especially, the diagnostic accuracy of HRCT is considered to be high. Magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT) allow both morphological and functional assessment of the lungs. In addition, biomarkers (e.g., KL-6, CCL2, or MUC5B) are being currently evaluated for the detection and prognostic assessment of ILD. Despite the accuracy of HRCT, invasive diagnostic methods such as bronchoalveolar lavage (BAL) and lung biopsy are still important in clinical practice. However, their therapeutic and prognostic relevance remains unclear. The aim of this review is to give an overview of the individual methods and to present their respective advantages and disadvantages in detecting and monitoring ILD in IRD-patients in the clinical routine.

Interstitial disease associated with connective tissue disease and vasculitis

Systemic autoimmune diseases comprise a complex, heterogeneous group of entities. Noteworthy among the pulmonary complications of these entities is interstitial involvement, which manifests with the same radiopathologic patterns as in idiopathic interstitial pneumonia. High-resolution computed tomography is the gold-standard imaging technique; it enables us to identify and classify the disease and to determine its extent, providing useful information about the prognosis. In this group of processes, the most common pattern of presentation is nonspecific interstitial pneumonia. It is essential for radiologists to work together in collaboration with other specialists to reach the correct diagnosis and enable appropriate, integrated treatment.

Two in one: Overlapping CT findings of COVID-19 and underlying lung diseases

Coronavirus disease 2019 (COVID-19) is associated with pneumonia and has various pulmonary manifestations on computed tomography (CT). Although COVID-19 pneumonia is usually seen as bilateral predominantly peripheral ground-glass opacities with or without consolidation, it can present with atypical radiological findings and resemble the imaging findings of other lung diseases. Diagnosis of COVID-19 pneumonia is much more challenging for both clinicians and radiologists in the presence of pre-existing lung disease. The imaging features of COVID-19 and underlying lung disease can overlap and obscure the findings of each other. Knowledge of the radiological findings of both diseases and possible complications, correct diagnosis, and multidisciplinary consensus play key roles in the appropriate management of diseases. In this pictorial review, the chest CT findings are presented of patients with underlying lung diseases and overlapping COVID-19 pneumonia and the various reasons for radiological lung abnormalities in these patients are discussed.

Atypical Causes of Dyspnea: A Review of Neuromuscular and Chest Wall Disorders that Compromise Ventilation

Dyspnea is a common presenting symptom among patients with cardiopulmonary diseases. However, several neuromuscular and chest wall conditions are often overlooked and under-recognized causes of dyspnea. These disorders frequently adversely affect the structure and function of the ventilatory pump (diaphragm, accessory muscles of ventilation) and can precipitate respiratory failure despite normal lung parenchyma. Weakened musculature impairs clearance of airway secretions leading to aspiration and pneumonia, further compromising respiratory function. Radiologists should be aware of the pathophysiology and imaging manifestations of these conditions and might suggest them to be causes of dyspnea which otherwise may not have been considered by referring clinicians.

Assessing the diagnostic value of a potential screening tool for detecting early interstitial lung disease at the onset of inflammatory rheumatic diseases

Background

Interstitial lung disease (ILD) is a severe pulmonary complication in inflammatory rheumatic diseases (IRD) and associated with significantly increased morbidity and mortality. That is why ILD screening at a very early stage, at the onset of IRD, is essential. The objective of the present study was to evaluate the diagnostic value and utility of a stepwise approach as a potential ILD screening tool in patients with newly diagnosed IRD.

Methods

Consecutively, 167 IRD patients were enrolled. To homogenize the study cohort, an age and gender matching was performed. The case-control study included 126 patients with new onset of IRD (mainly connective tissue diseases [CTD], small vessel vasculitis, and myositis). We applied a stepwise screening algorithm in which all patients underwent pulmonary function testing (PFT) and/or additional chest radiography. If there was at least one abnormal finding, pulmonary high-resolution computed tomography (HRCT) was subsequently performed.

Results

With our stepwise diagnostic approach, we identified 63 IRD patients with ILD (ILD group) and 63 IRD patients without ILD (non-ILD group). A reduced diffusing capacity for carbon monoxide (DLCO) < 80% showed a sensitivity of 83.6% and a specificity of 45.8% compared to chest X-ray with 64.2% and 73.6%, respectively, in detecting ILD. The combination of reduced DLCO and chest X-ray revealed a sensitivity of 95.2% and a specificity of 38.7%. The highest sensitivity (95.2%) and specificity (77.4%) were observed for the combination of reduced DLCO, chest X-ray, and pulmonary HRCT. The most common pulmonary abnormalities on HRCT were ground-glass opacities (GGO; 36.5%), followed by non-specific interstitial pneumonia (NSIP; 31.8%) and usual interstitial pneumonia (UIP; 9.5%).

Conclusions

The combination of reduced DLCO (< 80%), chest X-ray, and pulmonary HRCT yielded the highest sensitivity and specificity in detecting ILD at the onset of IRD. Therefore, this stepwise approach could be a new screening algorithm to identify IRD patients with pulmonary involvement already at the time of the initial IRD diagnosis.

Computed Tomography Predictors of Mortality or Disease Progression in Systemic Sclerosis–Interstitial Lung Disease: A Systematic Review

Objective

Although interstitial lung disease (ILD) is a major cause of morbidity and mortality in systemic sclerosis (SSc), its prognostication remains challenging. Given that CT represents the gold standard imaging technique in ILD assessment, a systematic review on chest CT findings as predictors of mortality or ILD progression in SSc-ILD was performed.

Materials and Methods

Three databases (Medline, Embase, and Web of Science) were searched to identify all studies analyzing CT mortality or ILD progression predictors in SSc-ILD, from inception to December 2020. ILD progression was defined by worsening of forced vital capacity and/or CT ILD findings. Manuscripts not written in English, with not available full-text, not focusing on SSc-ILD or with SSc-ILD not extrapolated, otherwise with overlap syndromes, pediatric patients, <10 cases or predictors other than CT features were excluded.

Results

Out of 3,513 citations, 15 full-texts (2,332 patients with SSc-ILD) met the inclusion criteria. ILD extent and extensive ILD, ILD densitometric analysis parameters, fibrotic extent and reticulation extent resulted as independent mortality predictors. Extensive ILD is also an independent predictor of death, need for supplemental oxygen or lung transplantation. Honeycombing extent is an independent risk factor for respiratory mortality. Independent predictors of ILD progression were not identified.

Conclusions

ILD extent and extensive ILD independently predict mortality in SSc-ILD on CT, as well as ILD densitometric analysis, fibrotic extent and reticulation extent. Extensive ILD is also a predictor of death, need for supplemental oxygen, or lung transplantation. Honeycombing extent predicts respiratory mortality. CT predictors of ILD progression need to be further investigated.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, PROSPERO, identifier: CRD420202005001.

A Machine Learning Application to Predict Early Lung Involvement in Scleroderma: A Feasibility Evaluation

Introduction: Systemic sclerosis (SSc) is a systemic immune-mediated disease, featuring fibrosis of the skin and organs, and has the greatest mortality among rheumatic diseases. The nervous system involvement has recently been demonstrated, although actual lung involvement is considered the leading cause of death in SSc and, therefore, should be diagnosed early. Pulmonary function tests are not sensitive enough to be used for screening purposes, thus they should be flanked by other clinical examinations; however, this would lead to a risk of overtesting, with considerable costs for the health system and an unnecessary burden for the patients. To this extent, Machine Learning (ML) algorithms could represent a useful add-on to the current clinical practice for diagnostic purposes and could help retrieve the most useful exams to be carried out for diagnostic purposes. Method: Here, we retrospectively collected high resolution computed tomography, pulmonary function tests, esophageal pH impedance tests, esophageal manometry and reflux disease questionnaires of 38 patients with SSc, applying, with R, different supervised ML algorithms, including lasso, ridge, elastic net, classification and regression trees (CART) and random forest to estimate the most important predictors for pulmonary involvement from such data. Results: In terms of performance, the random forest algorithm outperformed the other classifiers, with an estimated root-mean-square error (RMSE) of 0.810. However, this algorithm was seen to be computationally intensive, leaving room for the usefulness of other classifiers when a shorter response time is needed. Conclusions: Despite the notably small sample size, that could have prevented obtaining fully reliable data, the powerful tools available for ML can be useful for predicting early lung involvement in SSc patients. The use of predictors coming from spirometry and pH impedentiometry together might perform optimally for predicting early lung involvement in SSc.

THE ROLE OF CHEST CT IN DECIPHERING INTERSTITIAL LUNG INVOLVEMENT: SYSTEMIC SCLEROSIS VERSUS COVID-19

OBJECTIVE

To identify the main computed tomography (CT) features that may help distinguishing a progression of interstitial lung disease (ILD) secondary to Systemic sclerosis (SSc) from COVID-19 pneumonia.

METHODS

This multicentric study included 22 international readers divided in the radiologist group (RAD) and non-radiologist group (nRAD). A total of 99 patients, 52 with COVID-19 and 47 with SSc-ILD, were included in the study.

RESULTS

Fibrosis inside focal ground glass opacities (GGO) in the upper lobes; fibrosis in the lower lobe GGO; reticulations in lower lobes (especially if bilateral and symmetrical or associated with signs of fibrosis) were the CT features most frequently associated with SSc-ILD. The CT features most frequently associated with COVID- 19 pneumonia were: consolidation (CONS) in the lower lobes, CONS with peripheral (both central/peripheral or patchy distributions), anterior and posterior CONS and rounded-shaped GGOs in the lower lobes. After multivariate analysis, the presence of CONS in the lower lobes (p < 0.0001) and signs of fibrosis in GGO in the lower lobes (p < 0.0001) remained independently associated with COVID-19 pneumonia or SSc-ILD, respectively. A predictive score was created which resulted positively associated with the COVID-19 diagnosis (96.1% sensitivity and 83.3% specificity).

CONCLUSION

The CT differential diagnosis between COVID-19 pneumonia and SSc-ILD is possible through the combination the proposed score and the radiologic expertise. The presence of consolidation in the lower lobes may suggest a COVID-19 pneumonia while the presence of fibrosis inside GGO may indicate a SSc-ILD.

Interstitial Lung Disease Associated with Connective Tissue Diseases

Pulmonary manifestations of connective tissue diseases (CTD) carry high morbidity and potential mortality, and the most serious pulmonary type is interstitial lung disease (ILD). Identifying and promptly intervening CTD-ILD with immune suppressor therapy will change the natural course of the disease resulting in survival improvement. Compared to idiopathic pulmonary fibrosis, the most common presentation of idiopathic interstitial pneumonia (IIP), CTD-ILD carries a better prognosis due to the response to immune suppressor therapy. Nonspecific interstitial pneumonia (NSIP) is the most common type of CTD-ILD that is different from the fibrotic classical presentation of IPF, known as usual interstitial pneumonia (UIP). An exception is rheumatoid arthritis that presents more frequently with UIP type. Occasionally, IPF may not have typical radiographic features of UIP, and a full assessment to differentiate IPF from CTD-ILD is necessary, including the intervention of a multidisciplinary team and the histopathology. Interstitial pneumonia with autoimmune features (IPAF) shows promising advantages to identify patients with ILD who have some features of a CTD without a defined autoimmune disease and who may benefit from immune suppressors. A composition of clinical, serological, and morphologic features in patients presenting with ILD will fulfill criteria for IPAF. In summary, the early recognition and treatment of CTD-ILD, differentiation from IPF-UIP, and identification of patients with IPAF fulfill the assessment by the clinician for an optimal care.

A Review of Clinical and Imaging Features of Diffuse Pulmonary Hemorrhage

OBJECTIVE. The purpose of this article is to review the clinical and imaging features of diffuse pulmonary hemorrhage. CONCLUSION. Diffuse pulmonary hemorrhage is a life-threatening syndrome associated with a wide variety of underlying pathologic categories. Nonspecific clinical and imaging features pose challenges to promptly diagnosing this condition. Chest radiography commonly shows alveolar opacification, and CT reveals the extent of disease. Integration of clinical, radiologic, laboratory, and pathologic findings facilitates timely diagnosis and etiologic identification.

Histologic features suggesting connective tissue disease in idiopathic pulmonary fibrosis

Some patients with idiopathic pulmonary fibrosis (IPF) have histopathologic features suggesting connective tissue disease (CTD); however, their clinical course and prognosis remain unclear. Thus, we aimed to investigate the clinical course and prognosis of these patients with histologic autoimmune features. Among 114 patients with biopsy-proven IPF, the histologic features were semi-quantitatively graded, and CTD scores (range: 0-9) were calculated as the sum of each score of plasma cell infiltration, lymphoid aggregates, and germinal centres. Patients with high CTD scores (≥ 4) were classified into the interstitial pneumonia with histologic autoimmune features (IP-hAF) group. The mean age of the patients was 60.0 years; 74.6% were men, 69.3% were ever-smokers, and 35.1% had IP-hAF. During follow-up, the IP-hAF group showed slower decline in lung function, and better prognosis (median survival, 48.7 vs. 40.4 months; p = 0.015) than the no-IP-hAF group. On multivariate Cox analysis, IP-hAF was an independent prognostic factor (hazard ratio, 0.522; p = 0.016), along with the lower diffusing capacity for carbon monoxide, higher scores of reticulation and honeycombing, and usual interstitial pneumonia pattern on high-resolution computed tomography. Patients with IPF having histologic autoimmune features show distinct clinical characteristics and better outcome than those without histologic autoimmune features.

Pathological entities that may affect the lungs and the myocardium. Evaluation with chest CT and cardiac MR

Certain entities may simultaneously involve the lungs and the myocardium. Knowing their cardiac and thoracic manifestations enhances the understanding of those conditions and increases awareness and suspicion for possible concurrent cardiothoracic involvement. Entities that can present with pulmonary and myocardial involvement include infiltrative diseases like sarcoidosis and amyloidosis, eosinophil-associated conditions including eosinophilic granulomatosis with polyangiitis (EGPA) and hypereosinophilic syndrome (HES), connective tissue diseases such as systemic sclerosis (SSc) and lupus erythematosus and genetic disorders like Fabry disease (FD). Lung involvement in sarcoidosis is almost universal. While cardiac involvement is less common, concurrent cardiothoracic involvement can often be seen. Pulmonary amyloidosis is more often a localized process and generally occurs separately from cardiac involvement, except for diffuse alveolar-septal amyloidosis. EGPA and HES can present with consolidative or ground glass opacities, cardiac inflammation and endomyocardial fibrosis. Manifestations of SSc include interstitial lung disease, pulmonary hypertension and cardiomyopathy. Lupus can present with serositis, pneumonitis and cardiac inflammation. FD causes left ventricular thickening and fibrosis, and small airways disease. This article aims to review the clinicopathological features of chest and cardiac involvement of these entities and describe their main findings on chest CT and cardiac MR.

The Role of Imaging in COVID-19 Pneumonia Diagnosis and Management: Main Positions of the Experts, Key Imaging Features and Open Answers

Lung imaging is widely involved in facing the coronavirus disease (COVID-19) pandemic. In fact, the COVID-19 infection may lead to a rapidly evolving and potentially fatal pneumonia. Moreover, computed tomography (CT) can be more sensitive than the COVID-19 reverse transcriptase-polymerase chain reaction test, especially at the beginning of the disease. Only patients with mild features consistent with COVID-19 infection, negative COVID-19 test, or positive COVID-19 test but at low risk for disease progression should avoid imaging. However, imaging becomes mandatory if respiratory symptoms worsen. A CT pattern classification has been designed to help both radiologists and clinicians. The typical pattern of COVID-19 is depicted by multifocal, bilateral, and peripheral ground-glass opacities (with or without consolidations or crazy paving) or findings of organizing pneumonia. Moreover, CT has demonstrated a prognostic role in patients with a diagnosis of COVID-19 pneumonia. Lung ultrasounds (LUS) are an emergent tool in the diagnosis of the disease. The adoption of LUS combined to chest X-rays in COVID-19 in pneumonia diagnosis is an interesting prospect that needs to be confirmed.

Structured report for chest high-resolution computed tomography in patients with connective tissue disease: Impact on the report quality as perceived by referring clinicians

RATIONALE AND OBJECTIVES

To evaluate the impact on perceived report quality of referring rheumatologists for a chest high-resolution computed tomography (HRCT) structured report (SR) template for patients with connective tissue disease (CTD), compared to the traditional narrative report (NR).

MATERIALS AND METHODS

We retrospectively considered 123 HRCTs in patients with CTD. Three radiologists, blinded to the original NRs they wrote during clinical routine, re-reported each HRCT using an SR dedicated template. We then divided all NR-SR couples into three groups (41 HRCT each). Each group was evaluated by one of three rheumatologists (R1, R2, R3), who expressed their perceived report quality for the respective pools of NRs and SRs in terms of completeness, clarity (both on a 10-points scale), and clinical relevance (on a 5-points scale). The Wilcoxon test and the McNemar test were used for statistical analysis.

RESULTS

For each rheumatologist, SR received higher ratings compared to NR for completeness (median ratings: R1, 10 vs. 7; R2, 10 vs. 8; R3, 10 vs. 6, all p < 0.0001), clarity (median ratings: R1, 10 vs. 7; R2, 10 vs. 8; R3, 10 vs. 7, all p < 0.0001), and clinical relevance (median ratings: R1, 5 vs. 4; R2, 5 vs. 4; R3, 5 vs. 1, all p < 0.0001). After rating dichotomization, the use of SR led to a significant increase (p < 0.01) in completeness, clarity, and clinical relevance as compared to NR, except for clarity as perceived by R2 (p = 1).

CONCLUSION

Referring rheumatologists' perceived report quality for structured reporting of HRCT in patients with CTD was superior to narrative reporting.

Connective tissue disease--associated interstitial lung disease: an underreported cause of interstitial lung disease in Sub-Saharan Africa

Interstitial lung disease (ILD) occurs in 15% of connective tissue disease (CTD) patients causing considerable morbidity and mortality. Data is scarce regarding its clinical characteristics and outcomes in Africa. We aim to study the frequency, clinico-radiological characteristics, and treatment outcomes of African CTD-ILD patients. A retrospective cross-sectional study of ILD among 318 CTD patients diagnosed using relevant ACR criteria at the rheumatology unit of Lagos State University Teaching Hospital (LASUTH), Lagos from 2012 to 2019. Socio-demographics, clinical features, radiological findings, and treatment outcomes were documented. Data was analyzed using SPSS version 21 with p < 0.05. The LASUTH ethics committee approved the study. Interstitial lung disease occurred in 31 (9.7%) of 318 CTD cases. Their mean age was 38.8 ± 13.3 years, range 19-68 years with 28 (90.3%) females. Proportions of CTD-ILD were Sjogren's syndrome (50%), UCTD (50%), systemic sclerosis (46.7%), MCTD (33.3%), PM/DM (25%), SLE (6.5%), and RA (2.6%). Commonest presentations were cough (93.5%) and bibasal inspiratory crackles (83.9%) with a restrictive pattern in 83.9%. Antinuclear antibody occurred in 100% and anti-ENA in 67.7%. Traction bronchiectasis (89.7%) and ground glass opacities (96.6%) were frequent HRCT findings. Treatments included pulse-dose prednisolone, cyclophosphamide, mycophenolate mofetil, pirfenidone, and rituximab. Outcomes were ambulatory oxygen therapy (12.9%) and mortality (16.1%) with 9.7% lost to follow-up. CTD-ILD is a female predominant disease occurring in 9.7% of CTD patients mostly those with Sjogren's syndrome and systemic sclerosis. Due to significant morbidity and mortality, we advocate routine ILD screening for all CTD patients including those with undifferentiated disease. Key Points: • Interstitial lung disease occurs in 9.7% of patients with underlying connective tissue disease. • Females are predominantly affected especially those with Sjogren's syndrome and systemic sclerosis. • Mortality occurs in roughly 1 in every 6 patients with CTD-ILD.

Mixed Connective Tissue Disease With Retroperitoneal Fibrosis: A Rare Occurrence

Mixed connective tissue disease (MCTD) is an autoimmune condition characterized by mixed clinical features of connective tissue diseases like systemic lupus erythematosus, polymyositis or systemic sclerosis with high titers of anti-U1 small nuclear ribonucleoprotein. Interstitial lung disease is a frequent manifestation of MCTD. Retroperitoneal fibrosis (RPF) is a rare fibro-inflammatory process involving the retroperitoneum. Majority of the cases are idiopathic and the rest are secondary to malignancies, infections or drugs. In this article, we describe a rare occurrence of RPF with MCTD.

Methotrexate-Associated Pneumonitis and Rheumatoid Arthritis-Interstitial Lung Disease: Current Concepts for the Diagnosis and Treatment

Rheumatoid arthritis (RA) is a type of inflammatory arthritis that affects ~1% of the general population. Although arthritis is the cardinal symptom, many extra-articular manifestations can occur. Lung involvement and particularly interstitial lung disease (ILD) is among the most common. Although ILD can occur as part of the natural history of RA (RA-ILD), pulmonary fibrosis has been also linked with methotrexate (MTX); a condition also known as MTX-pneumonitis (M-pneu). This review aims to discuss epidemiological, diagnostic, imaging and histopathological features, risk factors, and treatment options in RA-ILD and M-pneu. M-pneu, usually has an acute/subacute course characterized by cough, dyspnea and fever. Several risk factors, including genetic and environmental factors have been suggested, but none have been validated. The diagnosis is based on clinical and radiologic findings which are mostly consistent with non-specific interstitial pneumonia (NSIP), more so than bronchiolitis obliterans organizing pneumonia (BOOP). Histological findings include interstitial infiltrates by lymphocytes, histiocytes, and eosinophils with or without non-caseating granulomas. Treatment requires immediate cessation of MTX and commencement of glucocorticoids. RA-ILD shares the same symptomatology with M-pneu. However, it usually has a more chronic course. RA-ILD occurs in about 3-5% of RA patients, although this percentage is significantly increased when radiologic criteria are used. Usual interstitial pneumonia (UIP) and NSIP are the most common radiologic patterns. Several risk factors have been identified for RA-ILD including smoking, male gender, and positivity for anti-citrullinated peptide antibodies and rheumatoid factor. Diagnosis is based on clinical and radiologic findings while pulmonary function tests may demonstrate a restrictive pattern. Although no clear guidelines exist for RA-ILD treatment, glucocorticoids and conventional disease modifying antirheumatic drugs (DMARDs) like MTX or leflunomide, as well as treatment with biologic DMARDs can be effective. There is limited evidence that rituximab, abatacept, and tocilizumab are better options compared to TNF-inhibitors.

[Mimics of lung cancer]

Lung cancer is a histologically, immunologically and therefore morphologically and functionally very heterogeneous group of neoplasms with the highest cancer mortality worldwide. Therefore, the range of diseases mimicking lung cancer is also very broad and includes congenital, infectious and inflammatory changes as well as other benign space-occupying lesions and other primary and secondary pulmonary neoplasms. The difficulty in radiology lies in the ability to diagnose lung cancer with a high degree of certainty. This must take the limits of the specific diagnosis, knowledge of the classical pitfalls and rare entities that can imitate lung cancer into consideration. Narrowing the differential diagnosis requires close interdisciplinary cooperation and consideration of the patient's clinical and medical history. An accurate analysis of the computed tomography (CT) pattern and distribution of the lesions as well as consideration of additional changes and involvement of other organ systems can be the key to the diagnosis. The use of fluorodeoxyglucose positron-emission tomography CT (FDG-PET-CT) is helpful only in a few mimics of lung cancer. The article describes clinical and radiological findings of mimics of lung cancer also pointing out the limitations of CT and PET-CT for the diagnosis.

Interstitial Lung Disease and Other Pulmonary Manifestations in Connective Tissue Diseases

Lung involvement in connective tissue diseases is associated with substantial morbidity and mortality, most commonly in the form of interstitial lung disease, and can occur in any of these disorders. Patterns of interstitial lung disease in patients with connective tissue disease are similar to those seen in idiopathic interstitial pneumonias, such as idiopathic pulmonary fibrosis. It may be difficult to distinguish between the 2 ailments, particularly when interstitial lung disease presents before extrapulmonary manifestations of the underlying connective tissue disease. There are important clinical implications in achieving this distinction. Given the complexities inherent in the management of these patients, a multidisciplinary evaluation is needed to optimize the diagnostic process and management strategies. The aim of this article was to summarize an approach to diagnosis and management based on the opinion of experts on this topic.

[Pulmonary fibrosis in rheumatic diseases]

Rheumatic diseases are frequently complicated by secondary pulmonary diseases, which often impair the quality of life and increase the mortality of patients. A correct classification of such pulmonary complications is important to ensure appropriate treatment and optimal prognosis. The diagnostic and therapeutic challenge is to find the precise diagnosis and appropriate therapy among the multitude of potential causes for respiratory symptoms. It is important to maintain a cautious approach to invasive diagnostics, even though the differential diagnostics of infections or toxic lung disease might be crucial. The situation is further complicated by the frequent lack of evidence for therapies. Especially in the case of pulmonary fibrosis which is comparable to cancer in its complexity and high mortality, the diagnostics and therapy should be discussed in appropriate interdisciplinary boards.

[Pulmonary manifestations in collagen vascular diseases]

CLINICAL/METHODICAL ISSUE

Pulmonary complications are frequent in patients with collagen vascular diseases (CVD). Frequent causes are a direct manifestation of the underlying disease, side effects of specific medications and lung infections.

STANDARD RADIOLOGICAL METHODS

The standard radiological procedure for the work-up of pulmonary pathologies in patients with CVD is multidetector computed tomography (MDCT) with thin-slice high-resolution reconstruction.

PERFORMANCE

The accuracy of thin-slice CT for the identification of particular disease patterns is very high. The pattern of usual interstitial pneumonia (UIP) representing the direct pulmonary manifestation of rheumatoid arthritis (RA) can be identified with a sensitivity of 45 % and a specificity of 96 %.

ACHIEVEMENTS

Both direct pulmonary manifestations, drug-induced toxicity and certain infections can have a similar appearance in thin-slice MDCT in various forms of CVD. Knowledge of the patterns and causes contributes to the diagnostic certainty.

PRACTICAL RECOMMENDATIONS

At first diagnosis of a CVD and associated pulmonary symptoms thin-slice MDCT is recommended. Clinical, lung function and imaging follow-up examinations should be performed every 6-12 months depending on the results of the MDCT. In every case the individual CT morphological patterns of pulmonary involvement must be identified. The combination of information on the anamnesis, clinical and imaging results is a prerequisite for an appropriate disease management.

Mixed connective tissue disease-enigma variations?

In 1972, Sharp et al. described a new autoimmune rheumatic disease that they called MCTD, characterized by overlapping features of SSc, SLE, PM/DM, high levels of anti-U1snRNP and low steroid requirements with good prognosis. MCTD was proposed as a distinct disease. However, soon after the original description, questions about the existence of such a syndrome as well as disputes over the features initially described began to surface. The conundrum of whether MCTD is a distinct disease entity remains controversial. We undertook a literature review, focusing on the articles reporting new data about MCTD published in the last decade, to determine whether any new observations help to answer the conundrum of MCTD. After reviewing recent data, we question whether the term MCTD is appropriately retained, preferring to use the term undifferentiated autoimmune rheumatic disease.

Role of Autoantibodies in the Diagnosis of Connective-Tissue Disease ILD (CTD-ILD) and Interstitial Pneumonia with Autoimmune Features (IPAF)

The diagnosis of interstitial lung disease (ILD) requires meticulous evaluation for an underlying connective tissue disease (CTD), with major implications for prognosis and management. CTD associated ILD (CTD-ILD) occurs most commonly in the context of an established CTD, but can be the first and/or only manifestation of an occult CTD or occur in patients who have features suggestive of an autoimmune process, but not meeting diagnostic criteria for a defined CTD-recently defined as "interstitial pneumonia with autoimmune features" (IPAF). The detection of specific autoantibodies serves a critical role in the diagnosis of CTD-ILD, but there remains a lack of data to guide clinical practice including which autoantibodies should be tested on initial assessment and when or in whom serial testing should be performed. The implications of detecting autoantibodies in patients with IPAF on disease behaviour and management remain unknown. The evaluation of CTD-ILD is challenging due to the heterogeneity of presentations and types of CTD and ILD that may be encountered, and thus it is imperative that immunologic tests are interpreted in conjunction with a detailed rheumatologic history and examination and multidisciplinary collaboration between respiratory physicians, rheumatologists, immunologists, radiologists and pathologists.

Pulmonary magnetic resonance imaging is similar to chest tomography in detecting inflammation in patients with systemic sclerosis

Interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are prevalent complications of systemic sclerosis (SSc) and are currently the leading causes of death related to the disease. The accurate recognition of these conditions is therefore of utmost importance for patient management. A study was carried out with 24 SSc patients being followed at the Rheumatology Department of the Hospital de Clínicas of Universidade Federal do Paraná (UFPR) and 14 healthy volunteers, with the objective of evaluating the usefulness of lung magnetic resonance imaging (MRI) when assessing ILD in SS patients. The results obtained with lung MRI were compared to those obtained by computed tomography (CT) of the chest, currently considered the examination of choice when investigating ILD in SS patients. The assessed population was predominantly composed of women with a mean age of 50 years, limited cutaneous SS, and a disease duration of approximately 7 years. In most cases, there was agreement between the findings on chest CT and lung MRI. Considering it is a radiation-free examination and capable of accurately identifying areas of lung tissue inflammatory involvement, lung MRI showed to be a useful examination, and further studies are needed to assess whether there is an advantage in using lung MRI instead of chest CT when assessing ILD activity in SS patients.

The Spectrum of Interstitial Lung Disease in Connective Tissue Disease

Interstitial lung disease (ILD) is a common cause of morbidity and mortality in patients with connective tissue disease (CTD). In a minority of patients the ILD may be the presenting (or only) manifestation of an underlying CTD. Diagnosis of CTD-related ILD relies on a multidisciplinary team including pulmonologists, pathologists, radiologists, and rheumatologists, as the imaging and pathologic findings may be indistinguishable from idiopathic interstitial pneumonias. Moreover, many patients with ILD are suspected of having an underlying CTD but do not meet all of the necessary criteria for a specific disorder. This article provides a pattern-based approach to the imaging of CTD-related ILD and also reviews relevant clinical, pathologic, and serologic data that radiologists should be familiar with as part of a multidisciplinary team.

Multidisciplinary Approach to Hypersensitivity Pneumonitis

Hypersensitivity pneumonitis (HP) may be a challenging diagnosis given the wide variability of its clinical, radiographic, and pathologic manifestations. A multidisciplinary approach to diagnosis is critical in maintaining a high specificity for HP. An in-depth knowledge of all 3 arms of the multidisciplinary approach helps clinicians, radiologists, and pathologists interpret their own findings in the context of the entire presentation. In some cases, the combination of clinical findings (ie, an identifiable exposure) and typical findings on high-resolution computed tomography is considered diagnostic of HP, and pathologic confirmation is not necessary. As many as 50% of patients do not have a clear exposure, however. These patients may be difficult to distinguish from idiopathic disorders. In these cases, high-resolution computed tomography and pathology are the primary data points that may suggest the correct diagnosis. The goal of this paper is to discuss recent advances in HP and to present the spectrum of clinical, radiographic, and pathologic findings.

An analysis of the clinical features of lung cancer in patients with connective tissue diseases

BACKGROUND

Patients with connective tissue diseases (CTDs) are at increased risk for lung cancer (LC); interstitial lung disease (ILD) is a common form of organ dysfunction in cases of CTD. However, the influence of ILD on the treatment and prognosis in LC patients with CTD is unclear.

METHODS

Between January 2010 and December 2014, 27 patients among all patients with CTD at our institution were diagnosed with primary LC. We retrospectively analyzed the clinical features, treatment modalities, and outcomes of these patients, and evaluated the potential prognostic factors. Forty-four LC patients without CTD were also analyzed as a control cohort.

RESULTS

LC patients with CTD had a significantly higher incidence of ILD as a complication compared with those without CTD (52% and 14%, respectively). CTD-associated ILD (CTD-ILD) at diagnosis was associated with significantly worse survival in LC patients with CTD. Multivariate analysis demonstrated that the complication of CTD-ILD was an independent poor prognostic factor in LC patients with CTD. The incidence of acute exacerbation (AE) of CTD-ILD was 21% among LC patients with CTD, and all of these patients died despite intensive treatment including high-dose corticosteroids. The restrictions in curative therapy for LC due to the presence of ILD and AE of CTD-ILD were thought to be the major reasons for the poor outcome.

CONCLUSIONS

LC patients with CTD had a high prevalence of ILD, and the presence of CTD-ILD was significantly associated with poor prognosis.

[Pulmonary fibrosis in rheumatic diseases]

Rheumatic diseases are frequently complicated by secondary pulmonary diseases, which often impair the quality of life and increase the mortality of patients. A correct classification of such pulmonary complications is important to ensure appropriate treatment and optimal prognosis. The diagnostic and therapeutic challenge is to find the precise diagnosis and appropriate therapy among the multitude of potential causes for respiratory symptoms. It is important to maintain a cautious approach to invasive diagnostics, even though the differential diagnostics of infections or toxic lung disease might be crucial. The situation is further complicated by the frequent lack of evidence for therapies. Especially in the case of pulmonary fibrosis which is comparable to cancer in its complexity and high mortality, the diagnostics and therapy should be discussed in appropriate interdisciplinary boards.

Sjögren's syndrome-associated interstitial lung disease: A multicenter study

Primary Sjögren syndrome (PSS) is a chronic inflammatory autoimmune disease. Interstitial lung disease (ILD) can be an extraglandular complication.

OBJECTIVE

To evaluate the clinical characteristics of patients diagnosed with PSS with ILD.

METHODS

Multicentre cohort study with 25 patients diagnosed with PSS and ILD. Data of PSS, prognostic factors, pulmonary involvement variables, complementary tests that suggest a worse diagnosis and treatment given were collected. EULAR index was measured for Sjögren's syndrome.

RESULTS

We identified 25 patients. In 15/25 the diagnosis of ILD was done before the diagnosis of PSS. The histopathological patterns found were: 12 NSIP, 5 UIP, 4 OP, 2 LIP. PFRs showed restrictive pattern. The majority of the patients received glucocorticoid therapy, antimalarial or immunosuppressive treatment.

CONCLUSIONS

Patients affected with PSS must be screened to catch a precocious diagnosis of ILD. The majority of the patients were diagnosed of ILD before being diagnosed of PSS. Multicenter cohorts are increasingly demanded and a multidisciplinary management is needed.

Intra-thoracic rheumatoid arthritis: Imaging spectrum of typical findings and treatment related complications

Non-cardiac thoracic manifestations of rheumatoid arthritis (RA) cause significant morbidity and mortality among RA patients. Essentially all anatomic compartments in the chest can be affected including the pleura, pulmonary parenchyma, airway, and vasculature. In addition, treatment-related complications and opportunistic infections are not uncommon. Accurate diagnosis of intra-thoracic disease in an RA patient can be difficult as the radiologic findings may be nonspecific and many of these conditions may coexist. This review article serves to highlight the multitude of RA-related intra-thoracic pathological processes, emphasize differential diagnosis, diagnostic conundrums and discuss how tailoring of CT imaging and image-guided biopsy plays a key role in the management of RA-related pulmonary disease.

Pulmonary tuberculosis in a patient with rheumatoid arthritis undergoig immunosuppressive treatment: case report

Rheumatoid arthritis is a disease which characteristically affects the joints. Because it is an autoimmune disease, immunosuppressive drugs are widely used in its treatment. The present case report illustrates the association of immunosuppressive treatment with the development of opportunistic infections in a 64-year-old patient.

Thorax: normal and benign pathologic patterns in FDG-PET/CT imaging

This article describes the normal patterns of thoracic (18)F-fluorodeoxyglucose (FDG) biodistribution, and expands on the role of FDG-PET/computed tomography (CT) for the evaluation of patients suffering from a spectrum of benign pathologic conditions that affect the chest. The discussion addresses the applications of FDG-PET/CT imaging in a wide variety of chest-related disorders. Familiarity with the normal thoracic biodistribution of FDG, coupled with knowledge of the potential nonmalignant causes of increased FDG uptake in the chest, is essential to minimize the incidence of incorrect interpretation of FDG-PET images in daily clinical practice.

Connective tissue disease-associated interstitial pneumonia and idiopathic interstitial pneumonia: similarity and difference

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.