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A3048 - A Rare Pulmonary Manifestation of Rheumatoid Arthritis
Author Block: H. Li1, S. Daouk2, A. Shahmohammadi3, C. Butler1, A. Ataya4; 1Internal Medicine, University of Florida Shands Hospital, Gainesville, FL, United States, 2medicine, pulmonary, critical care and sleep, university of florida, Gainesville, FL, United States, 3Medicine, Division of Pulmonary, Critical Care Medicine, University of Florida, Gainesville, FL, United States, 4University of Florida, Gainesville, FL, United States.
Rheumatoid arthritis (RA) is an inflammatory joint disease that affects about 1% of the population. Pulmonary complications are the most common extraarticular manifestations in RA and can precede articular disease in 10-20% of cases. A 64-year-old male with past medical history significant for hypertension presented with acute onset of shortness of breath. He was initially treated for community acquired pneumonia with antibiotics and noninvasive ventilation, but he quickly deteriorated and developed severe hypoxemic respiratory failure requiring endotracheal intubation and mechanical ventilatory support. Computed tomography (CT) scan of his chest revealed diffuse bilateral pulmonary ground glass infiltrates. Subsequently, bronchoscopy showed increasing bloody return on serial bronchioalveolar lavage of the left lower lobe; which was concerning for diffuse alveolar hemorrhage. Autoimmune work up showed rheumatoid factor (RF) of 44 IU/mL (3 times higher than normal) and Anti-cyclic citrullinated peptide (anti-CCP) of 201 units (10 times higher than normal). He received high dose corticosteroids and intravenous cyclophosphamide that was followed with improvement in clinical condition and imaging. Pulmonary findings are the most common extraarticular manifestations in RA; this includes nodules, airway, pleural, vascular and most commonly interstitial involvement. Rheumatoid arthritis associated interstitial lung disease (RA-ILD) has been reported to be present on high resolution computed tomography (HRCT) in up to 58% of patient with RA. Male sex and smoking history are most common risk factors for RA-ILD. RA-ILD typically presents as Usual Interstitial Pneumonia (UIP) or Non-Specific Interstitial Pneumonia (NSIP); however, it can rarely present as an acute interstitial pneumonia and diffuse alveolar damage. This case demonstrates two unusual presentations of RA: pulmonary manifestation as the only presentation and diffuse alveolar hemorrhage that is likely from pulmonary capillaritis secondary to RA. Diffuse alveolar hemorrhage is more commonly present in antineutrophil cytoplasmic antibody (ANCA) associated pulmonary vasculitides which this patient was tested negative for. Although uncommon, RF and anti-CCP should be tested in patients with diffuse alveolar hemorrhage with unclear etiology since the diagnosis of RA will determine short and long-term therapy options.