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Weekly Chest CasesArchive of Old Cases

Case No : 1010 Date 2017-03-06

  • Courtesy of Sung Shine Shim, MD., Yookyung Kim, MD. / Ewha Womans University
  • Age/Sex 49 / F
  • Chief Complaintmultiple joint pain
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6

Initial

Diagnosis With Brief Discussion

Diagnosis
Necrobiotic nodule
Radiologic Findings
1-2 : Chest PA show increase in size of a nodule in RULZ on 3months follow up chest simple radiograph
3-6: Well demarcated oval shaped nodule is noted in right upper lobe, adjacent posterior costal pleura without significant enhancement (HU 10). Several subpleural or pleural solid non-calcified nodules are also seen in right lung.
Brief Review
Rheumatoid arthritis is a chronic, immune- mediated illness wherein polyarthritis is most common presentation. Extra-articular manifestations are significant in prognostication, as they tend to correlate with mortality. In one study of 77 patients using HRCT of the chest, 22% of the patients were found to have rounded opacities in the characteristic location for rheumatoid pulmonary nodules being the second most commonly observed radiographic abnormality after bronchiectasis. Yousem and colleagues reported that 32.5% of RA patients undergoing open lung biopsy had rheumatoid nodules. Rheumatoid nodules are more common in men and in patients seropositive for rheumatoid factor.
Most rheumatoid nodules are small and asymptomatic. However, they may cause cough and hemoptysis. Cavitation with discharge of their central necrotic debris into an airway has also been reported. Most nodules are peripheral and subpleural in location. The enlargement and ultimately the rupture of a subpleural nodule can cause pleural effusions with dyspnea and chest pain, pneumothorax pyopneumothroax and bronchopleural fistula formation. Finally they may give rise to abscess or undergo calcification.
The differential diagnosis for cavitary pulmonary nodules may include ANCA positive granulomatous vasculitis, septic emboli, primary or secondary malignancies, amyloidosis, lymphoma, and tuberculosis though infection is the most likely cause. Importantly, malignancy and infections need to be ruled out, and tissue diagnosis is usually required. Rheumatoid nodules may remain stable or may regress spontaneously. In some cases they may enlarge and become symptomatic.
References
1. Cortet B, Flipo RM, Remy-Jardin M, Coquerelle P, Duquesnoy B, Remy J, et al. Use of high resolution computed tomography of the lungs in patients with rheumatoid arthritis. Annals of the rheumatic diseases. 1995 Oct;54(10):815-9.
2. Gauhar UA, Gaffo AL, Alarcon GS. Pulmonary manifestations of rheumatoid arthritis. Seminars in respiratory and critical care medicine. 2007 Aug;28(4):430-40.
3. Yousem SA, Colby TV, Carrington CB. Lung biopsy in rheumatoid arthritis. The American review of respiratory disease. 1985 May;131(5):770-7.
Keywords
Lung, Rheumatoid nodule , Necrobiotic nodule,

No. of Applicants : 118

▶ Correct Answer : 91/118,  77.1%
  • - Hyogo Prefectural Amagasaki General Medical Center , Japan TOMOAKI OTANI
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - Otsu Municipal Hospital , Japan NORIATSU ICHIBA
  • - Pamukkale University, Faculty of Medicine, Dept. of Radiology , Turkey Furkan Ufuk
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Yokohama-asahi-chuo-general hospital , Japan KYOKO NAGAI
  • - Shiga University of Medical Science , Japan AKITOSHI INOUE
  • - , India AKHILA DWARAKANATH
  • - The University of Tokyo Hospital , Japan Akifumi Hagiwara
  • - Chungbuk National University Hospital , Korea (South) YEONGTAE PARK
  • - King Abdulaziz University Hospital , Saudi Arabia Amr M. Ajlan
  • - McGill University Health Center , Canada Alexandre Semionov
  • - NIMS, HYDERABAD , India BHASKAR K
  • - Ajou university hospital , Korea (South) Pae Sun Suh
  • - The University of Tokyo Hospital , Japan Yusuke Watanabe
  • - Ondokuz Mayis University , Turkey CETIN CELENK
  • - Kyeongpook National University Hospital , Korea (South) CHUNGEUN LIM
  • - Chonnam National University Hwasun Hospital , Korea (South) INSOO JANG
  • - Chungbuk National University Hospital , Korea (South) SOOJUNG LEE
  • - Seoul National University Hospital , Korea (South) SU YEON AHN
  • - Other , Korea (South) HEE SEOK CHOI
  • - Other , Korea (South) SEONG SU KANG
  • - Scans world , India PHILSON JOSEPH MUKKADA
  • - PRINCE SATTAM IBN ABDULAZIZ UNIVERSITY HOSPITAL , Saudi Arabia ELBAGIR MOHAMED NASSIR
  • - Asan Medical Center , Korea (South) HYUN JUNG KOO
  • - , Korea (South)
  • - 遺€ , Korea (South) LEE YOU JIN
  • - Pusan national university hospital , Korea (South) MIRI JEONG
  • - Amagasaki General Medical Center , Japan GENKI FUKUMOTO
  • - privato , Italy VINCENZO ENZO GENCHI
  • - Chonnam National University Hospital , Korea (South) GUNSU KIM
  • - Chonnam National University Hospital , Korea (South) KIM GO EUN
  • - The Jikei university , Japan TAKU GOMI
  • - Kyungpook national university hospital , Korea (South) Nari Jung
  • - Pusan national university hospital , Korea (South) SeungHyun Lee
  • - Ajou University School of Medicine , Korea (South) YOOLIM BAEK
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Ajou University Hospital , Korea (South) Taeyang Ha
  • - The University of Tokyo Hospital , Japan Toshihiro Furuta
  • - Yonsei University, Wonju Severance Christian Hospital , Korea (South) JUYEON LEE
  • - Chonnam National University Hospital , Korea (South) JONG HYEON KIM
  • - HHS , Canada S LEE
  • - Seoul National University Hospital , Korea (South) JI EUN KIM
  • - Chung buk national university hospital , Korea (South) hong gwon Byun
  • - Asan Medical Center , Korea (South) JOOAE CHOE
  • - Chungbuk National University Hospital , Korea (South) JUNGHWAN KIM
  • - Samsung Medical Center , Korea (South) MIN YEONG KIM
  • - pusan national university hospital , Korea (South) kim jeongmyeong
  • - Samsung medical center , Korea (South) Ran Kim
  • - Dong-a University Medical Center , Korea (South) WON JIN CHOI
  • - Medicheck health care , Korea (South) Chae hun Lim
  • - Chungbuk National University Hospital , Korea (South) LEE JUNG HWAN
  • - Mallinckrodt Institute of Radiology , United States Naganathan BS Mani
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Other , Korea (South) HAYEON LEE
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Busan National University Hospital , Korea (South) CHANGMU LEE
  • - Kyeongpook National University Hospital , Korea (South) SUNGJUN MOON
  • - Centre Hospitalier Regional de Lanaudiere , Canada Matthieu Storme
  • - , Korea (South) HYERIN KIM
  • - Chungbuk national university hospital , Korea (South) Miran Yeon Yeon
  • - Seoul National University Hospital , Korea (South) KUM JU CHAE
  • - Soonchunhyang University Hospital Cheonan , Korea (South) CHAN HO PARK
  • - GHICL , France MANUEL TOLEDANO
  • - Konkuk University Medical Center , Korea (South) YONG WONN KWON
  • - Kanto Rosai Hospital , Japan TAKU TAJIMA
  • - Max Hospital New Delhi , India RAJESH GOTHI
  • - DECRH, Fredericton , Canada RAM P GALWA
  • - , Korea (South) RANG LEE
  • - Aerospace medical group, Air Force Education and Training Command , Korea (South) Donghwan Kim
  • - ICD,MCH CALICUT , India rikhy krishnan
  • - Korea university medical center, guro hospital , Korea (South) Lee kyu chong
  • - MBAL BURGAS , Bulgaria VLADISLAV BOYANOV RUSINOV
  • - Oita University , Japan HARUKA SATO
  • - , Korea (South) JINWOO HAN
  • - Ajou University Hospital , Korea (South) SEULGI YOU
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Samsung Medical Center , Korea (South) Jeonghyun Lee
  • - pusan national university hospital , Korea (South) jiwon lee
  • - , Korea (South) SUBIN HEO
  • - The University of Tokyo Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - Pusan National University Yangsan Hospital , Korea (South) JUNMEE YOU
  • - Dankook university hospital , Korea (South) Dabi Lee
  • - Private sector , Greece VASILIOS TZILAS
  • - University of Utah , United States AKIHIKO SAKATA
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Pusan national university hospital , Korea (South) So min Park
  • - Chungbuk National University Hospital , Korea (South) HYEONMI RYU
  • - Korea University Guro Hospital , Korea (South) Yoonmi Choi
  • - Korea University Ansan Hospital , Korea (South) CHERRY KIM
▶ Correct Answer as Differential Diagnosis : 10/118,  8.5%
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - IRSA LA ROCHELLE , France, Metropolitan BIGOT
  • - Busan National University Hospital , Korea (South) ILWAN SON
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Toshiba Hospital , Japan RYO KUROKAWA
  • - Avrasya Hospital/ISTANBUL , Turkey MURAT ULUSOY
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - University of Illinois at Chicago , United States GYE YOUNG PARK
  • - Manipal hospitals , India ELAKYA ARUL
  • - Korea University Guro Hospital , Korea (South) HWANSEOK YONG
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