Ultrasound in Rheumatologic Interstitial Lung Disease: A Case Report of Nonspecific Interstitial Pneumonia in Rheumatoid Arthritis

Unmet needs and perspectives in rheumatoid arthritis-associated interstitial lung disease: A critical review

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by synovitis as the most common clinical manifestation, and interstitial lung disease (RA-ILD) represents one of the most common and potentially severe extra-articular features. Our current understanding of the mechanisms and predictors of RA-ILD is limited despite the demonstration that an early identification of progressive fibrosing forms is crucial to provide timely treatment with antifibrotic therapies. While high resolution computed tomography is the gold standard technique for the diagnosis and follow-up of RA-ILD, it has been hypothesized that serum biomarkers (including novel and rare autoantibodies), new imaging techniques such as ultrasound of the lung, or the application of innovative radiologic algorithms may help towards predicting and detecting early forms of diseases. Further, while new treatments are becoming available for idiopathic and connective tissue disease-associated forms of lung fibrosis, the treatment of RA-ILD remains anecdotal and largely unexplored. We are convinced that a better understanding of the mechanisms connecting RA with ILD in a subgroup of patients as well as the creation of adequate diagnostic pathways will be mandatory steps for a more effective management of this clinically challenging entity.

Ultrasonographic evaluation of lung parenchyma involvement in sarcoidosis

Purpose

To use ultrasonography (USG) for the evaluation of lung parenchyma in patients with sarcoidosis, andto compare the USG findings with the results of a high-resolution computerized tomography (HRCT) and pulmonary function test-carbon monoxide diffusion test (PFT-DLCO), which are commonly used methods in the evaluation of parenchymal involvement in sarcoidosis.

Material and Methods

Patients with sarcoidosis and healthy controls were enrolled in the study between January 2015 and December 2017. The clinical findings, HRCT and PFT-DLCO results of all subjects were recorded, and USG findings and comet tail artifact (CTA) measurements were recorded by another pulmonologist. The USG, HRCT and SFT-DLCO findings were compared between the two groups. Based on the findings of theclinical-radiologic investigations and PFT-DLCO, as the current gold standard in diagnosis, the sensitivity and specificity of USG in demonstrating lung parenchyma involvement in sarcoidosis patients were estimated.

Findings

The sarcoidosis group consisted of 79 patients and the control group included 34 subjects. The mean number of CTAs in the sarcoidosis and control groups was 33.4 and 25, respectively (p=0.001). In the sarcoidosis group, the number of CTAs in patients with DLCO% <80 and ≥80% was 37.4 and 29.7, respectively (p=0.011), and a negative correlation was identified between the number of CTAs and DLCO% (p=0.019 r=-0.267). The mean number of CTAs in patients with and without parenchymal involvement in HRCT was 36 and 25.5, respectively (p=0.001). The number of CTAs in the patients with sarcoidosis with a normal DLCO% value (≥80%) was higher than in the control group (p=0.014). The diagnostic sensitivity and specificity of thoracic USG were found to be 76% and 53%, respectively.

Conclusion

The number of CTAs in patients with sarcoidosis was higher than that of the healthy controls. The number of CTAs in patients with sarcoidosis with parenchymal involvement in HRCT and/or a low DLCO (<80%) was also elevated. Thoracic USG has a high sensitivity (76%) in demonstrating parenchymal involvement in patients with sarcoidosis.

Utilize lung ultrasound B-lines and KL-6 to monitor anti-MDA-5 antibody-positive clinically amyopathic dermatomyositis-associated interstitial lung disease: a case report and literature review

In the past decade, lung ultrasound (LUS) B-lines and serum Krebs von den Lungen-6 (KL-6) antigen have been recognized as biomarkers of the connective tissue disease-associated interstitial lung diseases (CTD-ILDs). Robust data have demonstrated that B-lines total numbers and KL-6 levels are correlated with high-resolution computed tomography findings, pulmonary function test, and some clinical parameters in CTD-ILDs. However, limited data are available regarding the use of these two biomarkers to follow CTD-ILDs. Herein, we report a case with anti-melanoma differentiation-associated gene 5 antibody-positive clinically amyopathic dermatomyositis-associated ILD, successfully treated with high-dose methylprednisolone, cyclophosphamide, intravenous immunoglobulin, pirfenidone, and followed using lung ultrasound and KL-6.

Interstitial Lung Disease as the Initial Manifestation of Rheumatoid Arthritis: A Case Report and Review of the Literature

BACKGROUND

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder that primarily affects synovial joints. Approximately 18-41% of patients with RA develop extra-articular manifestations [1]. However, extra-articular manifestations preceding or occurring without articular symptoms in RA have rarely been reported. Such atypical presentations of RA pose a diagnostic challenge to the clinician and may delay treatment.

CASE PRESENTATION

A 57-year-old female with long standing diabetes, hypertension, hyperlipidemia and Raynaud's phenomenon presented shortness of breath, cough and new subcutaneous nodules. Four years before, she had been diagnosed with non specific interstitial pneumonia but had declined treatment. The physical exam did not reveal any signs suggestive of RA however, she was seropositive for rheumatoid factor (RF) and anti-citrullinated peptide antibody (ACPA). Treatment for RA-associated interstitial lung disease was discussed.

CONCLUSION

Extra-articular involvement of RA can be observed as initial presentation of the disease in a handful of cases. However, RA diagnosis must be achieved to correctly manage these patients which can at that time receive targeted therapeutic interventions. From our literature review, pulmonary involvement was seen in over half of the cases in seropositive RA patients who lacked articular involvement at initial presentation.

Usefulness of lung ultrasound B-lines in connective tissue disease-associated interstitial lung disease: a literature review

Interstitial lung disease (ILD) is a major pulmonary manifestation of connective tissue disease (CTD), leading to significant morbidity and mortality. Chest high-resolution computed tomography (HRCT) is presently considered the diagnostic gold standard for pulmonary fibrosis diagnosis and quantification in the clinical arena. However, not negligible doses of ionizing radiation limit the use of HRCT, especially for serial follow-up in younger female patients. In the past decade, lung ultrasound (LUS) has been proposed to assess ILD by detecting and quantifying sonographic B-lines. Previous studies demonstrate that B-lines have a good diagnostic accuracy, especially high sensitivity, and correlate well with HRCT findings, suggesting LUS as a novel, non-invasive, and non-ionizing imaging method to be used in patients with CTD-ILD. Although preliminary data are promising, challenges and controversies still remain. For example, the mechanisms of B-line generation are not fully understood; the diagnostic accuracy and performance characteristics of LUS partially depend on the scanning scheme and scoring system used; and up-to-date B-lines cannot discriminate the early cellular inflammation from the chronic fibrotic phase in CTD-ILD. Therefore it is important for clinicians to understand the strengths and limitations of LUS in CTD-ILD patients, to maximize its value.