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Recognizing lung disease in patients with rheumatoid arthritis, part 1.

Article Excerpt
ABSTRACT: Pulmonary manifestations, such as pleural effusions, interstitial lung disease (ILD), and rheumatoid nodules, are common in patients with rheumatoid arthritis (RA). For those with pleural effusions, diagnostic thoracentesis is usually necessary to rule out other causes. Larger effusions that cause dyspnea may require therapeutic thoracentesis or other interventions. The presentation of ILD is characterized by gradually progressive dyspnea on exertion and cough. An isolated decrement in carbon monoxide-diffusing capacity is often the earliest abnormality seen on pulmonary function testing. Highresolution CT is an important tool for detecting ILD; common findings include ground-glass opacities and reticulation. It is important to keep in mind that in RA-associated ILD, more than one pathological process-often several-may be seen in the same patient.

KEY WORDS: Rheumatoid arthritis, Interstitial lung disease

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Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by morning stiffness and symmetrical polyarthritis, particularly of the hand and wrist joints. (1) Additional elements include elevated levels of rheumatoid factor, the presence of rheumatoid nodules, and radiographic evidence of joint erosions and deformities. Bony changes seen on chest radiographs include resorption of the distal clavicles and erosive arthritis of the shoulders.

RA typically affects women 2 to 3 times more often than men. However, with a 1% prevalence worldwide, millions of men also suffer from the disease. (2) Disease-modifying antirheumatic drugs are usually used for early and aggressive treatment of articular inflammation, with the goal of minimizing long-term disability. Newer biological agents, such as tumor necrosis factor (TNF-[alpha]) antagonists, are increasingly being used as well.

In addition to joint disease, extra-articular manifestations are common in patients with RA. In particular, the lung is affected and respiratory complaints may precede joint symptoms in some cases. The most common pulmonary manifestations include interstitial lung disease (ILD), rheumatoid nodules, and pleural effusions. However, any part of the respiratory system may be involved, from the upper airway to the alveoli (Table).

In a 2-part article, we will review the various pulmonary manifestations of RA. In part 1, we focus on pleural involvement and ILD. In part 2, we will discuss airway diseases, such as bronchiectasis, bronchiolitis obliterans, rheumatoid nodules, drug-induced lung diseases, and pulmonary infections.

BACKGROUND

When evaluating patients with RA who have pulmonary symptoms or radiographic abnormalities, a broad differential diagnosis should be maintained. RA-associated pleuropulmonary disease is often a diagnosis of exclusion. The possibility of infection, drug-induced lung disease, and other disease entities must be entertained. Since smoking appears to be related to the development of RA, underlying smoking-related diseases may be seen concomitantly with RA-related lung disease. (3) Patients with RA also appear to be at increased risk for coronary artery disease, diastolic dysfunction, and congestive heart failure, making a cardiac cause of shortness of breath an important consideration. (4,5)

The initial evaluation includes a careful medical and exposure history, pulmonary function testing, and high-resolution CT (HRCT). Exercise studies may uncover milder disease in active patients. Invasive testing may be required for definitive diagnosis or to rule out infection before empiric treatment is begun.

Symptomatic or progressive disease may respond to corticosteroids and other immunosuppressive medications, but careful follow-up is required. The role of screening for the presence of underlying respiratory disease in all patients with RA or in patients for whom the use of disease-modifying antirheumatic drugs is being considered is not clear at present, but when pulmonary manifestations occur, baseline parameters are helpful.

PLEURAL DISEASE

Pleuritis and pleural effusion

* Epidemiology: Pleural involvement, which includes pleural thickening and...

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