대한흉부영상의학회 Weekly Chest Cases

Case No : 879 Date 2014-09-01

Courtesy of 1. Soon Ho Yoon, Sang Min Lee, Hyun Ju Lee / Seoul National University Hospital
Age/Sex 79 / M
Chief ComplaintIncidental abnormality on chest radiograph. He had been treated with anti-tumor necrosis factor-alpha I antibody one year ago.

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Diagnosis With Brief Discussion

Diagnosis: Rheumatoid nodule
Radiologic Findings: Initial chest radiograph showed multiple nodular opacities in right lung and left lower lung zone. Some of these lesions had cavity. Subsequent chest CT scan showed similar findings with chest radiograph. There were multifocal subpleural cavitating or non-cavitating nodules ranging from 1 to 3 cm in diameter in right lung and lingular segment of LUL. A portion of these lesions had a relatively thick irregular wall. A follow-up CT scan two months after steroid treatment showed most of these lesions shrank mildly and internal cavitation partly collapsed. The video-assisted thoracic lung biopsy was performed. The final pathologic diagnosis was consistent with rheumatoid nodule. He was diagnosed as having rheumatoid arthritis one year ago.
Brief Review: Thoracic involvement of rheumatoid arthritis includes pleural disease, interstitial pneumonitis, airway disease and rheumatoid nodule. Rheumatoid nodules in lung parenchyma are a very rarely reported. They are frequently found in male patients with positive rheumatoid factor, smokers and patients having subcutaneous rheumatoid nodules. It may precede clinical manifestation of arthritis. Typical CT features of pulmonary rheumatoid nodules are well-defined, multiple rounded nodules with varing size from a few millimeter to 7 cm in diameter. They tend to locate in the subpleural area of lung periphery or in association with interlobular septa. Up to 50%, they may have cavity and lead to complications such as pleural effusion, hemoptysis, pneumothorax, and broncho-pleural fistula. They are generally asymptomatic and don’t usually require a specific treatment. Recently, there has been several studies reporting accelerated pulmonary rheumatoid nodulosis after the treatment of anti-tumor necrosis factor therapy. Accelerated pulmonary nodulosis were mainly presented with etanercept and manifested in patients receiving associated disease-modifying anti-rheumatic drugs including methotrexate or leflunomide. They tend to be not associated with cutaneous nodulosis. Pathophysiologic mechanisms of accelerated pulmonary nodulosis are not well-understood. Radiologists need to be aware of accelerated pulmonary rheumatoid nodulosis maybe developing during the anti-tumor necrosis factor therapy in patients with rheumatoid arthritis.
References: 1.Gómez Herrero H1, 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.
2.Kim SH, Yoo WH. Recurrent pneumothorax associated with pulmonary nodules after leflunomide therapy in rheumatoid arthritis: a case report and review of the literature. Rheumatol Int. 2011 Jul;31(7):919-22.
3.Toussirot E1, Berthelot JM, Pertuiset E, Bouvard B, Gaudin P, Wendling D, le Noach J, Lohse A, Lecuyer E, Cri L. Pulmonary nodulosis and aseptic granulomatous lung disease occurring in patients with rheumatoid arthritis receiving tumor necrosis factor-alpha-blocking agent: a case series. J Rheumatol. 2009 Nov;36(11):2421-7.
Keywords: Lung, Connective tissue diseases, RA,

No. of Applicants : 68

▶ Correct Answer : 19/68, 27.9%

- The University of Tokyo Hospital , Japan Toshihiro Furuta
- 異⑸ , Korea (South) Yunhee Jang
- chungbuk national university hospital , Korea (South) soojung lee
- MBAL BURGAS , Bulgaria VLADISLAV RUSINOV
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- Univ Teach Hospital of Reunion Island , Reunion HO Fabien
- Saint Malo , France jean-baptiste Noel
- Wuhan Union Hospital , China Qiguang Cheng
- The University of Tokyo Hospital , Japan Takeyuki Watadani
- Chia Nan University of Pharmacy and Science ,Taiwan, R.O.C. , Taiwan Jun Jun Yeh
- NIMS, HYDERABAD , India bhaskar kakarla
- Kizawa Memorial Hospital , Japan Yo Kaneko
- National Hospital Organization Okinawa Hospital , Japan Yasuji Oshiro
- Pulmonary Institute, Shaare Zedek Medical Center , Israel Abraham Bohadana
- Severance hospital , Korea (South) Beomseok Sohn
- SNUH , Korea (South) Eui Jin Hwang
- Centre Imagerie de Fribourg , Switzerland Benoit Rizk
- Medicheck health care , Korea (South) Chae Lim
- Northern Yokohama Showa university , Japan Kota Watanabe

▶ Correct Answer as Differential Diagnosis : 22/68, 32.4%

- Niigata City General Hospital , Japan Takao Kiguchi
- Kyoto University , Japan Akihiko Sakata
- Chungbuk national university , Korea (South) Yong Kim
- IRSA La Rochelle , France Denis Chabassiere
- McGill University Health Center , Canada Alexandre Semionov
- Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
- district tuberculosis centre,poonamallee , India gayathri ganesh
- CLCC Rennes , France nicolas gautier
- Shiga University of Medical Science , Japan Akitoshi Inoue
- IRSA LA ROCHELLE , France, Metropolitan BIGOT
- Fortis hospital , Mohali , India Shaleen Rana
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- Ibaraki-gazou-shindan , Japan Shoichi Katoh
- 異⑸ , Korea (South) Junghwan Kim
- jaslok hospital & research centre mumbai , India JAINENDRA JAIN
- Royal Perth Hospital , Australia Yuranga Weerakkody
- Pamukkale University, Faculty of Medicine, Dept. of Radiology , Turkey Furkan Ufuk
- Onomichi municipal hospital , Japan Hirofumi Mifune
- Gifu Central Hospital , Japan Haruo Watanabe
- National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
- ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
- Private sector , Greece Vasilios Tzilas

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 879 Date 2014-09-01

Discussion

No. of Applicants : 68