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Weekly Chest CasesArchive of Old Cases

Case No : 655 Date 2010-05-17

  • Courtesy of Sewon Oh, MD, Yo Won Choi, MD. / Hanyang University Seoul Hospital, Korea.
  • Age/Sex 57 / M
  • Chief Complaint57/M work up for interstitial lung disease
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2008-12-13

Diagnosis With Brief Discussion

Diagnosis
Rheumatoid nodule confirmed by open lung biopsy in a patient with rheumatoid arthritis.
Radiologic Findings
12/13 chest CT
- Nonspecific noncalcified lung nodule in left upper lobe anterior segment.
- Underlying ILD

12/23 chest CT
- Newly developed cavitary nodule and non-calcified lung nodule at both lung.
- No interval change of lung nodule in left upper lobe anterior segment.
Brief Review
Pulmonary nodules are uncommon manifestations of rheumatoid disease and identified in less than 1% of chest radiographs of patients with RA. These nodules occur most often in seropositive men who smoke and have subcutaneous nodules.
They are frequently located in the periphery of the right middle or both upper lobes, range from several millimeters to several centimeters in diameter, and may be single or multiple.
Central cavitation occurs in about half of the nodules and calcification is rare. These nodules are usually asymptomatic. 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. Caplan뭩 syndrome represents an association of pulmonary nodules and pneumoconiosis in patients with RA.
Histologically, rheumatoid pulmonary nodules are characterized by a central zone of fibrinoid necrosis, surrounded by a layer of palisading mononuclear cells within an outer zone of vascular granulation tissue, lymphocytes, histiocytes, plasma cells, and fibroblasts. Although the pathogenesis of the nodules is unknown, vasculitis caused by immune complex deposition has been implicated
References
1. P. Gupta, F. Ponzo and E.L. Kramer, Fluorodeoxyglucose (FDG) uptake in pulmonary rheumatoid nodules, Clin Rheumatol 24 (2005), pp. 402-405.
2. Anaya JM, Diethelm L, Ortiz LA, Gutierrez M, Gustavo C, Welsh RA, Espinoza LR (1995) Pulmonary involvement in rheumatoid arthritis. Semin Arthritis Rheum 24:242-254.
3. Yousem SA, Colby TV, Carrington CB (1985) Lung biopsy in rheumatoid arthritis. Am Rev Respir Dis 131:770-777.
Keywords
Lung, Connective tissue diseases, RA,

No. of Applicants : 95

▶ Correct Answer : 22/95,  23.2%
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - Osaka University , Japan Osamu Honda
  • - CHU NANCY , France, Metropolitan GREGORY LESANNE
  • - University of British Columbia , Canada Amr Ajlan
  • - SoonChunHyang univ. hospital , Korea (South) Kim Jae Hyun
  • - SMC , Korea (South) Yi Kyung Kim
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - Seoul National University Hospital , Korea (South) Sung Ui Shin
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Sunchun university hospital, Bucheon , Korea (North) So Young
  • - Assam Medical college , India samudra borah
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - SUT Hospital , India Hari Krishnan
  • - Seoul National University Hospital , Korea (South) Hyungjin Kim
  • - IRCCS Istituto Oncologico - Bari , Italy Carlo Florio
  • - jobless , France jean-baptiste Noel
  • - SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OKUBO
  • - KMC,Manipal , India satish maddukuri
  • - Apollo Gleneagles hosp kolkata , India SALIM PARVEZ
  • - HIA Legouest , France Alban Gervaise
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - Chonnam university hospital , Korea (South) Minyoung Jung
▶ Correct Answer as Differential Diagnosis : 9/95,  9.5%
  • - Hospital M�e de Deus , Brazil Thiago Bento da Silva
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - ROYAL MELBOURNE HOSPITAL , Australia kimchi kings
  • - PingTung Christian Hospital ,China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - , Bulgaria VLADISLAV RUSINOV
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - NASA SCANS NEW DELHI , India RAKESH BHATIA
  • - PITTWATER RADIOLOGY , Australia Saurabh Khandelwal
  • - PITTWATER RADIOLOGY , Australia Julie Arora
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