대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Rheumatoid nodules

Radiologic Findings

Initial chest PA shows a calcific nodular opacity suggesting old TB lesion in right upper field. And follow-up chest PA shows newly developed several small nodular opacities in the both lungs.
Axial constrast enhanced chest CT images show a noncalcified nodule with internal low density area adjacent calcific density in right upper lobe. And also multiple subpleural variable sized(5mm-15mm) noncalcified nodules are detected.
The patient had a medical history of seropositive rheumatoid arthritis. A video-assisted thoracoscopic biopsy was performed and pathologic specimens revealed the area of fibrinoid necrosis, findings consistent with rheumatoid nodule(necrobiotic nodule)

Brief Review

Pulmonary rheumatoid nodules, also called necrobiotic nodules are a rare manifestation of rheumatoid arthritis (RA). Their prevalence ranges from less than 0.4% in radiological studies. However, similar to other pulmonary manifestations of RA, rheumatoid nodules are observed more frequently when more sensitive modalities are used. In one review, lung biopsy specimens showed rheumatoid nodules in 32% of patients with RA. In a review of HRCT findings, 49% of patients with RA were found to have nodules.
It has been reported that they occur more frequently in male patients with positive rheumatoid factor (RF), smokers and those with subcutaneous nodules.
They are defined as rounded, multiple nodules, and more rarely as solitary nodules with a size ranging from millimeters to 7 cm. The frequent distribution of rheumatoid nodules is in the subpleural areas or the interlobular septae in the middle and superior peripheral lobe. Up to 50% may cavitate, and be usually asymptomatic or accompanied by an associated pleural effusion, pneumothorax or hydropneumothorax.
The clinical course of pulmonary rheumatoid nodules varies substantially. The nodules may precede clinical evidence of RA or may be seen concurrently, may increase in size, resolve spontaneously, or appear at new sites as older nodules are resolving.
Histologically, typical rheumatoid nodules,containing three histologically distinct zones, central fibrinoid necrosis, surrounding palisading epithelioid cells and an outer zone of lymphocytes, plasma cells and fibroblasts.

References

1.Yousem SA, Colby TV, Carrington CB. Lung biopsy in rheumatoide arthritis. Am Rev Respir Dis. 1985;131:770-7
2. Jolles H, Moseley PL, Peterson MW. Nodular pulmonary opacities in patients with rheumatoid arthritis. A diagnostic dilemma. Chest. 1989;96:1022-5
3. Hull S, Mathews JA. Pulmonary necrobiotic nodules as a presenting feature of rheumatoid arthritis. Ann Rheum Dis. 1982;41:21-4
4. Atsuko Kitamura,Tadakatsu Matsuno,Michihiko Narita, Rheumatoid arthritis with diffuse pulmonary rheumatoid nodules. Pathology International 2004;54:798-802

Please refer to

Case 655

Keywords

Lung, Connective tissue diseases, RA,