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*Only for medical professionals to read for reference, learn to recognize rheumatoid nodules! Common respiratory complications of rheumatoid arthritis (RA) include interstitial lung disease, bronchitis, alveolitis, pulmonary vasculitis, pulmonary rheumatoid nodules, and pulmonary hypertension.
Rheumatoid nodules are the most common skin manifestation of RA.
Pulmonary rheumatoid nodules found by imaging studies are not very rare.
Such nodules can also be found in other organs.
When pulmonary nodules appear in RA patients, it is easy for clinicians to preconceived that the lung lesions are pulmonary rheumatoid nodules.
On the other hand, for patients with no history of RA, sometimes when pulmonary rheumatoid nodules are accidentally found by imaging, it is also easy to misdiagnose before biopsy.
In addition to the skin, lung parenchyma is an important site of rheumatoid nodules in RA patients.
Pulmonary rheumatoid nodules may also become the first manifestation of RA patients.
The occurrence of pulmonary rheumatoid nodules has no obvious correlation with the progression of arthritis, and may even appear earlier than arthritis.
Imaging studies have shown that the prevalence of pulmonary rheumatoid nodules is 0.
4%-1%, but the lung autopsy reports of RA patients show that the proportion is as high as 32% [1-2].
The susceptibility factors of pulmonary rheumatoid nodules are similar to those of subcutaneous rheumatoid nodules.
Pulmonary rheumatoid nodules are more likely to be seen in men, smoking and serum rheumatoid factor-positive patients, accompanied by subcutaneous rheumatoid nodules, and long-term use of methotrexate [1-2].
Most pulmonary rheumatoid nodules are asymptomatic, and the patients are mainly found by chest X-ray, chest CT and other imaging methods.
Pulmonary rheumatoid nodules usually appear as solitary nodules or multiple pulmonary nodules in the lung parenchyma.
Multiple nodules are more common than single nodules.
The size of the nodules ranges from several millimeters to several centimeters and is mainly located in the periphery of the upper middle and upper lungs.
The pleura is the base [1,3].
Many pulmonary rheumatoid nodules are round or round-like high-density nodules.
Sagdeo P et al.
reported in the BMJ Case Rep magazine a 61-year-old woman who received a combination of methotrexate and leflunomide for 6 years due to seropositive RA [2].
The patient has no history of smoking, and had seen a doctor with dyspnea that lasted for 3 months 6 months ago.
The patient's chest radiograph showed multiple nodules in the upper left lung and lower right lung.
Chest CT showed multiple necrotizing and non-necrotic nodules in both lungs.
The CT-guided needle biopsy showed that it was a pulmonary rheumatoid nodule with no evidence of vasculitis, malignant tumor, or infection.
Figure 1 Chest CT (axial + coronal reconstruction image) shows multiple round-like pulmonary rheumatoid nodules in both lungs.
[2] About 50% of pulmonary rheumatoid nodules appear as hollow nodules, which may be caused by rupture pneumothorax.
In addition to pneumothorax, pulmonary rheumatoid nodules may also cause complications such as pleural effusion, bleeding, or liquid pneumothorax.
For example, the following is a chest X-ray and chest CT of an RA patient, in which a hollow pulmonary rheumatoid nodule with a size of about 1.
1 cm in the upper right lung and middle left lung can be seen, with light-transmitting shadows (red and yellow arrows) visible in the center, lower right The lungs can be seen with hollow pulmonary rheumatoid nodules with encapsulated pneumothorax (blue arrow) [1].
Figure 2 Chest radiograph and chest CT of a RA patient: multiple cavitary pulmonary rheumatoid nodules (red and yellow arrows) in both lungs, rheumatoid nodules in the right lower lung with encapsulated pneumothorax (blue arrows) [1] No complications The pulmonary rheumatoid nodules usually do not require special treatment.
Without treatment, the patient's pulmonary rheumatoid nodules may gradually progress, disappear or remain unchanged.
The outcome trend of pulmonary rheumatoid nodules and RA seems to lack consistency, and may even worsen after treatment with tumor necrosis factor inhibitors, which is similar to subcutaneous rheumatoid nodules.
Are the lung nodules in RA patients all pulmonary rheumatoid nodules? It should be noted that the pulmonary nodules in RA patients are not all pulmonary rheumatoid nodules.
Due to the large number of differential diagnoses, the diagnosis of pulmonary rheumatoid nodules in the absence of biopsy results is quite challenging.
Regardless of the history of RA, bronchial lung cancer or lung metastases are important differential diagnoses of lung nodules, especially in patients with smoking and immunocompromised immune function.
However, the patient's clinical manifestations, laboratory examinations, and chest radiographs are often difficult to distinguish due to the lack of specific signs.
At this time, lung nodule biopsy is of great significance, especially for patients with a single lung nodule.
A retrospective cohort study of 73 patients with RA with pulmonary nodules (with histological evidence) conducted by scholars from the Mayo Clinic showed that compared with patients with malignant pulmonary nodules, patients with pulmonary rheumatoid nodules were younger (on average) 59 years old), often accompanied by subcutaneous rheumatoid nodules (73%) and positive serum rheumatoid factor (93%) [4].
In chest CT findings, when RA patients have at least 3 of the 6 signs located in the periphery of the lung field, subpleural nodules, multiple (≥4), smooth edges, hollow-like, and satellite nodules, it is useful for the diagnosis of pulmonary rheumatoid Nodules have the highest sensitivity (77%) and specificity (92%) (AUC 0.
85) [4].
PET scan or PET-CT scan is a kind of non-invasive examination that is helpful to distinguish benign and malignant pulmonary nodules in RA patients.
Pulmonary rheumatoid nodules are manifested as pulmonary nodules or corresponding hilar lymph nodes that do not take up or only take up radionuclide imaging agent at a low level.
For example, a 64-year-old female RA patient with sero-positive results showed a nodule with a diameter of 2.
1 cm in the upper right lung on chest X-ray and chest CT.
Bronchoscopy and transthoracic fine needle aspiration could not be diagnosed.
PET scans suggest an increase in the uptake of the corresponding lung nodules and hilar area, so it is highly suggestive of malignant nodules.
The patient was finally confirmed by thoracoscopic biopsy as bronchial lung cancer [5].
Figure 3 A 64-year-old woman with RA: PET scan revealed increased uptake in the right upper lung lung nodules and hilar area [5] In addition to malignant tumors, when multiple cavitary pulmonary nodules appear in RA patients, the common differential diagnosis also includes granulomatous multiple Vasculitis and other autoimmune diseases, infectious diseases (bacteria such as tuberculosis, Nocardia, and aspergillosis), etc.
It should be noted that granuloma with polyangiitis is the most common autoimmune disease with cavitary lung disease [6].
Even if the patient has a history of pulmonary rheumatoid nodules, when new pulmonary nodules are found on imaging, one should be alert to the possibility of the above differential diagnosis.
In BMJ Case Rep, Saba R et al.
reported a case of a 35-year-old man with a history of RA, pulmonary rheumatoid nodules, and Graves disease.
He presented to the doctor with new fever, progressive dyspnea and cough.
Compared with the chest CT image two years ago, the number and size of the patient's lung nodules have increased, and new nodules accompanied by gas-liquid flatness can be seen on the right lung apex.
The patient was finally confirmed by bronchial biopsy as granulomatous polyangiitis [6].
Figure 4 Chest radiograph and chest CT of a 35-year-old man with a history of RA and pulmonary rheumatoid sarcoidosis showed multiple lung nodules in both lungs.
The puncture pathology of the new nodule at the right lung tip was granulomatous polyangiitis[6] As mentioned above, pulmonary rheumatoid nodules are a pulmonary manifestation of RA patients, which are more common in men, smoking and serum rheumatoid factor positive patients with subcutaneous rheumatoid nodules.
The chest CT features of pulmonary rheumatoid nodules include multiple (≥4), located in the periphery of the lung field, smooth margins, subpleural nodules, cavities, and satellite nodules.
Not all pulmonary nodules appearing in RA patients are rheumatoid nodules.
Patients without a history of RA may also have pulmonary rheumatoid nodules as the first manifestation.
Lung malignant tumors (primary lung cancer or metastases), other autoimmune diseases (granulomatous polyangiitis), infection (tuberculosis), etc.
are common differential diagnoses.
Therefore, lung nodule biopsy may be of great significance for the clear diagnosis and differential diagnosis.
Reference: [1]Tilstra JS,Lienesch DW.
Rheumatoid Nodules.
Dermatol Clin.
2015 Jul;33(3):361-71.
doi:10.
1016/j.
det.
2015.
03.
004.
PMID:26143419.
[2]Sagdeo P,Gattimallanahali Y,Kakade G,Canchi B.
Rheumatoid lung nodule.
BMJ Case Rep.
2015 Oct 29;2015:bcr2015213083.
doi:10.
1136/bcr-2015-213083.
PMID:26516255;PMCID:PMC4636694.
[3]Gómez Herrero H, Arraiza Sarasa M, Rubio Marco I, García de Eulate Martín-Moro I.
Pulmonary rheumatoid nodules: presentation, methods, diagnosis and progression in reference to 5 cases.
Reumatol Clin.
2012 Jul-Aug;8(4):212- 5.
English,Spanish.
doi:10.
1016/j.
reuma.
2011.
09.
004.
Epub 2012 Jan 20.
[4]Koslow M,Young JR,Yi ES,Baqir M,Decker PA,Johnson GB,Ryu JH.
Rheumatoid pulmonary nodules :clinical and imaging features compared with malignancy.
Eur Radiol.
2019 Apr;29(4):1684-1692.
doi:10.
1007/s00330-018-5755-x.
Epub 2018 Oct 4.
PMID:30288558.
[5]Rodríguez P ,Romero T,Rodríguez de Castro F, Hussein M, Freixinet J.
Bronchogenic carcinoma associated with rheumatoid arthritis:role of FDG-PET scans.
Rheumatology(Oxford).
2006 Mar;45(3):359-60.
doi:10.
1093/rheumatology/kel006.
Epub 2006 Jan 25.
PMID:16436491.
[6]Saba R,Ali AM,Kwatra SG,Mirrakhimov AE.
New pulmonary nodules in a patient with rheumatoid arthritis.
BMJ Case Rep.
2013 Feb 6;2013:bcr2012008344.
doi:10.
1136/ bcr-2012-008344.
PMID:23391958;PMCID:PMC3604260.
PMC3604260.
PMC3604260.
Rheumatoid nodules are the most common skin manifestation of RA.
Pulmonary rheumatoid nodules found by imaging studies are not very rare.
Such nodules can also be found in other organs.
When pulmonary nodules appear in RA patients, it is easy for clinicians to preconceived that the lung lesions are pulmonary rheumatoid nodules.
On the other hand, for patients with no history of RA, sometimes when pulmonary rheumatoid nodules are accidentally found by imaging, it is also easy to misdiagnose before biopsy.
In addition to the skin, lung parenchyma is an important site of rheumatoid nodules in RA patients.
Pulmonary rheumatoid nodules may also become the first manifestation of RA patients.
The occurrence of pulmonary rheumatoid nodules has no obvious correlation with the progression of arthritis, and may even appear earlier than arthritis.
Imaging studies have shown that the prevalence of pulmonary rheumatoid nodules is 0.
4%-1%, but the lung autopsy reports of RA patients show that the proportion is as high as 32% [1-2].
The susceptibility factors of pulmonary rheumatoid nodules are similar to those of subcutaneous rheumatoid nodules.
Pulmonary rheumatoid nodules are more likely to be seen in men, smoking and serum rheumatoid factor-positive patients, accompanied by subcutaneous rheumatoid nodules, and long-term use of methotrexate [1-2].
Most pulmonary rheumatoid nodules are asymptomatic, and the patients are mainly found by chest X-ray, chest CT and other imaging methods.
Pulmonary rheumatoid nodules usually appear as solitary nodules or multiple pulmonary nodules in the lung parenchyma.
Multiple nodules are more common than single nodules.
The size of the nodules ranges from several millimeters to several centimeters and is mainly located in the periphery of the upper middle and upper lungs.
The pleura is the base [1,3].
Many pulmonary rheumatoid nodules are round or round-like high-density nodules.
Sagdeo P et al.
reported in the BMJ Case Rep magazine a 61-year-old woman who received a combination of methotrexate and leflunomide for 6 years due to seropositive RA [2].
The patient has no history of smoking, and had seen a doctor with dyspnea that lasted for 3 months 6 months ago.
The patient's chest radiograph showed multiple nodules in the upper left lung and lower right lung.
Chest CT showed multiple necrotizing and non-necrotic nodules in both lungs.
The CT-guided needle biopsy showed that it was a pulmonary rheumatoid nodule with no evidence of vasculitis, malignant tumor, or infection.
Figure 1 Chest CT (axial + coronal reconstruction image) shows multiple round-like pulmonary rheumatoid nodules in both lungs.
[2] About 50% of pulmonary rheumatoid nodules appear as hollow nodules, which may be caused by rupture pneumothorax.
In addition to pneumothorax, pulmonary rheumatoid nodules may also cause complications such as pleural effusion, bleeding, or liquid pneumothorax.
For example, the following is a chest X-ray and chest CT of an RA patient, in which a hollow pulmonary rheumatoid nodule with a size of about 1.
1 cm in the upper right lung and middle left lung can be seen, with light-transmitting shadows (red and yellow arrows) visible in the center, lower right The lungs can be seen with hollow pulmonary rheumatoid nodules with encapsulated pneumothorax (blue arrow) [1].
Figure 2 Chest radiograph and chest CT of a RA patient: multiple cavitary pulmonary rheumatoid nodules (red and yellow arrows) in both lungs, rheumatoid nodules in the right lower lung with encapsulated pneumothorax (blue arrows) [1] No complications The pulmonary rheumatoid nodules usually do not require special treatment.
Without treatment, the patient's pulmonary rheumatoid nodules may gradually progress, disappear or remain unchanged.
The outcome trend of pulmonary rheumatoid nodules and RA seems to lack consistency, and may even worsen after treatment with tumor necrosis factor inhibitors, which is similar to subcutaneous rheumatoid nodules.
Are the lung nodules in RA patients all pulmonary rheumatoid nodules? It should be noted that the pulmonary nodules in RA patients are not all pulmonary rheumatoid nodules.
Due to the large number of differential diagnoses, the diagnosis of pulmonary rheumatoid nodules in the absence of biopsy results is quite challenging.
Regardless of the history of RA, bronchial lung cancer or lung metastases are important differential diagnoses of lung nodules, especially in patients with smoking and immunocompromised immune function.
However, the patient's clinical manifestations, laboratory examinations, and chest radiographs are often difficult to distinguish due to the lack of specific signs.
At this time, lung nodule biopsy is of great significance, especially for patients with a single lung nodule.
A retrospective cohort study of 73 patients with RA with pulmonary nodules (with histological evidence) conducted by scholars from the Mayo Clinic showed that compared with patients with malignant pulmonary nodules, patients with pulmonary rheumatoid nodules were younger (on average) 59 years old), often accompanied by subcutaneous rheumatoid nodules (73%) and positive serum rheumatoid factor (93%) [4].
In chest CT findings, when RA patients have at least 3 of the 6 signs located in the periphery of the lung field, subpleural nodules, multiple (≥4), smooth edges, hollow-like, and satellite nodules, it is useful for the diagnosis of pulmonary rheumatoid Nodules have the highest sensitivity (77%) and specificity (92%) (AUC 0.
85) [4].
PET scan or PET-CT scan is a kind of non-invasive examination that is helpful to distinguish benign and malignant pulmonary nodules in RA patients.
Pulmonary rheumatoid nodules are manifested as pulmonary nodules or corresponding hilar lymph nodes that do not take up or only take up radionuclide imaging agent at a low level.
For example, a 64-year-old female RA patient with sero-positive results showed a nodule with a diameter of 2.
1 cm in the upper right lung on chest X-ray and chest CT.
Bronchoscopy and transthoracic fine needle aspiration could not be diagnosed.
PET scans suggest an increase in the uptake of the corresponding lung nodules and hilar area, so it is highly suggestive of malignant nodules.
The patient was finally confirmed by thoracoscopic biopsy as bronchial lung cancer [5].
Figure 3 A 64-year-old woman with RA: PET scan revealed increased uptake in the right upper lung lung nodules and hilar area [5] In addition to malignant tumors, when multiple cavitary pulmonary nodules appear in RA patients, the common differential diagnosis also includes granulomatous multiple Vasculitis and other autoimmune diseases, infectious diseases (bacteria such as tuberculosis, Nocardia, and aspergillosis), etc.
It should be noted that granuloma with polyangiitis is the most common autoimmune disease with cavitary lung disease [6].
Even if the patient has a history of pulmonary rheumatoid nodules, when new pulmonary nodules are found on imaging, one should be alert to the possibility of the above differential diagnosis.
In BMJ Case Rep, Saba R et al.
reported a case of a 35-year-old man with a history of RA, pulmonary rheumatoid nodules, and Graves disease.
He presented to the doctor with new fever, progressive dyspnea and cough.
Compared with the chest CT image two years ago, the number and size of the patient's lung nodules have increased, and new nodules accompanied by gas-liquid flatness can be seen on the right lung apex.
The patient was finally confirmed by bronchial biopsy as granulomatous polyangiitis [6].
Figure 4 Chest radiograph and chest CT of a 35-year-old man with a history of RA and pulmonary rheumatoid sarcoidosis showed multiple lung nodules in both lungs.
The puncture pathology of the new nodule at the right lung tip was granulomatous polyangiitis[6] As mentioned above, pulmonary rheumatoid nodules are a pulmonary manifestation of RA patients, which are more common in men, smoking and serum rheumatoid factor positive patients with subcutaneous rheumatoid nodules.
The chest CT features of pulmonary rheumatoid nodules include multiple (≥4), located in the periphery of the lung field, smooth margins, subpleural nodules, cavities, and satellite nodules.
Not all pulmonary nodules appearing in RA patients are rheumatoid nodules.
Patients without a history of RA may also have pulmonary rheumatoid nodules as the first manifestation.
Lung malignant tumors (primary lung cancer or metastases), other autoimmune diseases (granulomatous polyangiitis), infection (tuberculosis), etc.
are common differential diagnoses.
Therefore, lung nodule biopsy may be of great significance for the clear diagnosis and differential diagnosis.
Reference: [1]Tilstra JS,Lienesch DW.
Rheumatoid Nodules.
Dermatol Clin.
2015 Jul;33(3):361-71.
doi:10.
1016/j.
det.
2015.
03.
004.
PMID:26143419.
[2]Sagdeo P,Gattimallanahali Y,Kakade G,Canchi B.
Rheumatoid lung nodule.
BMJ Case Rep.
2015 Oct 29;2015:bcr2015213083.
doi:10.
1136/bcr-2015-213083.
PMID:26516255;PMCID:PMC4636694.
[3]Gómez Herrero H, Arraiza Sarasa M, Rubio Marco I, García de Eulate Martín-Moro I.
Pulmonary rheumatoid nodules: presentation, methods, diagnosis and progression in reference to 5 cases.
Reumatol Clin.
2012 Jul-Aug;8(4):212- 5.
English,Spanish.
doi:10.
1016/j.
reuma.
2011.
09.
004.
Epub 2012 Jan 20.
[4]Koslow M,Young JR,Yi ES,Baqir M,Decker PA,Johnson GB,Ryu JH.
Rheumatoid pulmonary nodules :clinical and imaging features compared with malignancy.
Eur Radiol.
2019 Apr;29(4):1684-1692.
doi:10.
1007/s00330-018-5755-x.
Epub 2018 Oct 4.
PMID:30288558.
[5]Rodríguez P ,Romero T,Rodríguez de Castro F, Hussein M, Freixinet J.
Bronchogenic carcinoma associated with rheumatoid arthritis:role of FDG-PET scans.
Rheumatology(Oxford).
2006 Mar;45(3):359-60.
doi:10.
1093/rheumatology/kel006.
Epub 2006 Jan 25.
PMID:16436491.
[6]Saba R,Ali AM,Kwatra SG,Mirrakhimov AE.
New pulmonary nodules in a patient with rheumatoid arthritis.
BMJ Case Rep.
2013 Feb 6;2013:bcr2012008344.
doi:10.
1136/ bcr-2012-008344.
PMID:23391958;PMCID:PMC3604260.
PMC3604260.
PMC3604260.
