대한흉부영상의학회 Weekly Chest Cases

Case No : 841 Date 2013-12-09

Courtesy of Bo Eun Lee, Yookyung Kim / Ewha Womans University Mokdong Hospital
Age/Sex 38 / M
Chief ComplaintDyspnea (Hx: Rheumatoid arthritis, ex-smoker (10 pack years))

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Diagnosis With Brief Discussion

Diagnosis: Rheumatoid arthritis related interstitial pneumonitis
Radiologic Findings: Initial CT scan shows diffuse bilateral subpleural interlobular and intralobular septal thickenings, consolidation, traction bronchiectasis, and honeycombing, predominantly in upper lung zone. Poorly-defined centrilobular nodules, brancing structures and bronchiolectasis with random distribution are noted in both lungs. Also noted are consolidation in left lower lobe due to combined pneumonia and diffuse left pleural thickening. Follow-up CT scan 2 years later shows interval progression of interlobular and peribronchovascular interstitial thickenings, bronchiolectasis, and centrilobular nodules, particularly in lower lung zones. Coronal images well demonstrate subpleural and pleural fibrosis with honeycombing in upper lobes, and interlobular and peribronchovascular interstitial thickenings and centrilobular nodules in lower lobes.
Wedge resections were performed from right upper, middle, and lower lobes. Histopathologic examination demonstrated interstitial pneumonitis with subpleural and septal fibrosis, pleural fibrosis with adhesion to parietal pleura, vascular thickening, cholesterol granuloma, lymphoid hyperplasia, and honeycomb cystic change, clinically associated with rheumatoid arthritis.
Brief Review: Rheumatoid arthritis is a common systemic disease that manifests as inflammatory arthritis of multiple joints and produces a wide variety of intrathoracic lesions, including pleural diseases, rheumatoid nodules, diffuse interstitial pneumonia, pulmonary vasculitis, and airway disease that includes bronchiectasis, bronchiolitis obliterans, and follicular bronchiolitis.
Interstitial lung disease (ILD) is a common extra-articular manifestation of rheumatoid arthritis (RA) and is associated with substantial morbidity and mortality. Histologic patterns of RA-associated ILD include usual interstitial pneumonia (UIP, most common pattern), nonspecific interstitial pneumonia (NSIP), organizing pneumonia, diffuse alveolar damage, lymphoid interstitial pneumonia, bronchiolitis obliterans, and follicular bronchiolitis (1).
RA-ILD with UIP pattern is associated with increased mortality and less responsive to conventional treatment compared with RA-ILD with non-UIP pattern. Therefore accurate identification of RA-ILD patients with UIP pattern is important. In patients with RA-ILD, a definite CT UIP pattern, characterized by basal and subpleural interstitial reticulations and fibrosis, traction bronchiectasis, and honeycombing, has a specificity of 96% and a sensitivity of 45% for the histopathologic UIP pattern. More than half of RA patients with UIP pattern do not show typical CT feature of UIP (2)
References: 1. Tanaka N, Kim JS, Newell JD, et al. Rheumatoid arthritis-related lung disease: CT findings. Radiology 2004; 232:81-91
2. Assayag D, Elicker BM, Urbania TH, et al. Rheumatoid arthritis-associated interstitial lung disease: radiologic identification of usual interstitial pneumonia pattern. Radiology. 13018710.1148 /radiology.13130187 Posted online on 28 Oct 2013
Keywords: Lung, Connective tissue diseases, RA,

No. of Applicants : 63

▶ Correct Answer : 19/63, 30.2%

- Niigata City General Hospital , Japan Takao Kiguchi
- Kyoto University , Japan Akihiko Sakata
- Kyung Hee University Hospital at Gangdong , Korea (South) Seong Jong Yun
- University of British Columbia , Canada Amr Ajlan
- humiic , Korea (South) Ju Won Lee
- Nagasaki University Hospital, Department of Pathology , Japan TOMONORI TANAKA
- PIMS , India padhmini balasubramanian
- ACE DIAGNOSTICS , India DAMANDEEP CHAWLA
- Kizawa Memorial Hospital , Japan Yo Kaneko
- Intermed Hospital , Mongolia Khulan Khurelsukh
- Ishikawa Matto Central Hospital , Japan Manabu Akimoto
- Saint Malo , France jean-baptiste Noel
- Tokyo Metropolitan Police Hospital , Japan Akifumi Hagiwara
- CLINIQUE STE CLOTILDE , Reunion patrick MASCAREL
- C.B.H. Dpt of Imaging-Clinica , Italy Carlo Florio
- Chonnam National Univ. Hospital , Korea (South) Jaemyeong Jo
- Medicheck health care , Korea (South) Chae Lim
- Fukuyama City Hospital , Japan Mayu Uka
- SNUH , Korea (South) Eui Jin Hwang

▶ Correct Answer as Differential Diagnosis : 13/63, 20.6%

- Onomichi municipal hospital , Japan Hirofumi Mifune
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- Oita University, Faculty of Medicine , Japan Fumito Okada
- Hopital Bichat , France, Metropolitan Pauline Pradere
- kanto Rosai Hp , Japan Takana Yamakawa
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- Asan medical center , Korea (South) Hyun Joo Lee
- Niigata University , Japan Atsushi Uehara
- IRSA La Rochelle , France Denis Chabassiere
- GHOL, Hopital de Nyon , Switzerland Benoit Rizk
- Asan medical center , Korea (South) Cherry Kim
- CAC Rennes , France nicolas gautier
- Kyungpook National University Hospital , Korea (South) Jaekwang Lim

▶ Semi-Correct Answer : 10/63, 15.9%

- Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
- Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
- prince salman bin abdulaziz university , Saudi Arabia NABIL GHALEB
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN
- Dept. Radiology, Kyungpook medical school hosipital , Korea (South) Hyejin Cheon
- SKG radiology , Australia Yuranga Weerakkody
- Ondokuz Mayis University , Turkey Cetin Celenk
- district tuberculosis centre,poonamallee , India gayathri ganesh
- Bach Mai hospital , Viet Nam Hoi Nguyen
- CHU POITIERS , France SZTARK Guillaume

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 841 Date 2013-12-09

Discussion

No. of Applicants : 63