Female patient with clinical presentation of headache, nausea, photophobia and vomiting, history of surgical interventions 4 months ago due to sphenoid mucopyocelle and severe Rheumatoid arthritis proven two years ago. Routine chest radiograph was done due to suspicion of bronchitis. Laboratory test results show inflammation /WBC 13 10^9/l, CRP 91 mg/l, ESR 30 mm/h/.
Fig. 1 Chest X-ray
Fig. 2 Axial CT through the upper chest
Fig. 3 Axial CT through the lower chest
Background: Rheumatoid arthritis /RA/ is an chronic autoimmune, inflammatory connective tissue disease, characterized by arthritis, but also may have extra-articular involvement (1). Rheumatoid nodules occur in one-third of the patients with seropositive disease, most often in subcutaneous tissue (2). However pulmonary rheumatoid nodules are quite rare. These nodules generally do not cause any clinical symptoms and so usually they are incidental findings. Drugs, such as methotrexate, anti-TNF agents and activity of the disease (high levels of ESR, CRP, WBC, RF) can cause the appearance of pulmonary nodules. Pathophysiologically rheumatoid nodules belong to Th1-mediated granulomas and are characterized with central fibrinoid necrosis, epithelioid cells around an outer zone with lymphocytes, plasma cells or fibroblasts. The central zone may become cavity due to the resolution of necrosis (3) as in the present case.
Clinical perspective: The patient is diagnosed with severe RA two years ago and treated with methotrexate and TNF blockers. Immunocompromised patients are at possible risk of all the above-mentioned conditions, however, most of them have clinical manifestations. In this case, there was no history of clinical symptoms from the respiratory system. The last chest X-ray performed 4 months ago was with normal finding – no evidence of pulmonary lesions.
Imaging perspective: Pulmonary X-ray was done on the day before the hospitalization due to suspicion of bronchitis revealed mix sized bilateral (cavitating) pulmonary lesions (Fig.1). The followed CT examination confirmed the presence of two cavitating nodular lesions, located bilateral, with irregular margins. There was no evidence of hilar enlargement, pleural effusion, enlarged lymph nodes or other disorders of the lung structure. Imaging methods alone are not sufficient for definitive diagnosis, therefore, suspicious lesions should be identified by histopathology (Fig. 2 and Fig.3). The diagnosis was made based on the clinical and imaging findings, histopathology results and the negative cultures.
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 Kanıtez NA, Çelik S, Öner SY, Ürer HN, Bes C, Çetinkaya E (2018) Cavitary pulmonary nodules in rheumatoid arthritis; case reports and review of the literature. Eur J Rheumatol 5(1): 65–68 (PMID: 30501854)