대한흉부영상의학회 Korean Society of Thoracic Radiology

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Weekly Chest CasesCases by Disease Category

Case No : 1180 Date 2020-06-04

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  • Courtesy of Minji Song, Young Hun Jeon, Jin Young Yoo / Chungbuk National University Hospital
  • Age/Sex 78 / M
  • Chief ComplaintCough and arthralgia
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • Figure 7
  • Figure 8

on admission

Diagnosis With Brief Discussion

Diagnosis
Rheumatoid nodules
Radiologic Findings
Figure 1. Postero-anterior chest radiograph taken on admission shows diffusely distributed multiple nodular opacities in both lung fields.
Figure 2 to 4. Chest CT images on admission demonstrate multiple heterogenous nodules in predominantly subpleural area of both lungs.
Figure 5. Mildly FDG uptaken nodules are noted in right upper lobe on PET/CT.
Figure 6 to 8. In comparison with chest CT on admission, axial CT images taken 7 months ago show smaller solid nodules in right upper lobe and left lower lobe.

Initial diagnosis of rheumatoid nodule was confirmed following right lower lobe wedge resection.
Brief Review
Rheumatoid arthritis is a systemic inflammatory disorder that commonly affects the joints, causing the progressive, symmetric, and erosive destruction of cartilage and bone in conjunction with autoantibody production. Rheumatoid arthritis affects 1% of the population in developed countries. There are also a number of extra-articular manifestations, including subcutaneous nodule formation, vasculitis, inflammatory eye disease and lung disease. Among these manifestations, lung disease is a major contributor to morbidity and mortality. In some cases, respiratory symptoms may precede articular symptoms. Respiratory symptoms in rheumatoid arthritis can be caused by a variety of conditions that affect the parenchyma, pleura, airways or vasculature. The majority of respiratory manifestations occur within the first 5 years of disease. Pulmonary involvement may reflect chronic immune activation, increased susceptibility to infection (often related to immunomodulatory medications) or direct toxicity from disease modifying or biological therapy. Prognosis varies depending on the type and severity of involvement.
While RA-ILD is the most common form of pulmonary involvement, rheumatoid nodules can also occur, particularly in patients with longstanding disease and subcutaneous nodules. On HRCT, they are typically located along the interlobular septa or in subpleural regions. Nodules may be single or multiple, ranging in size from a few millimetres to several centimetres. Nodules are typically asymptomatic unless they cavitate or rupture, in which case infection, pleural effusion or bronchopleural fistula may occur. Uncomplicated nodules may spontaneously regress or improve with standard rheumatoid arthritis therapy. However, rheumatoid nodules have, at times, been noted to paradoxically enlarge with rheumatoid arthritis treatment, with enlargement being observed specifically in methotrexate treatment cases. In patients who are past or current smokers, it is important to differentiate nodules from malignancy. Positron emission tomography scans may be used in the evaluation of nodules 8 mm in diameter; in general, rheumatoid nodules show little or no uptake on positron emission tomography scans, although increased uptake may be seen if active inflammation is present.
Please refer to
Case 655, Case 798, Case 879, Case 1010, Case 1041,
KSTR imaging conference cases 2010 Sprng  Case 11,
References
Shaw, M., Collins, B. F., Ho, L. A., & Raghu, G. (2015). Rheumatoid arthritis-associated lung disease. European Respiratory Review, 24(135), 1-16.
Keywords
lung, rheumatoid arthritis, rheumatoid nodule, necrobiotic nodule,

No. of Applicants : 79

▶ Correct Answer : 55/79,  69.6%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - Saitama-Sekishinkai Hosptal , Japan MIHOKO YAMAZAKI
  • - , Japan HIROAKI ARAKAWA
  • - ZIGONG TCM HOSPITAL OF CHINA , China Cao Cunyou
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - radiologist, aditya imaging centre , India VIVEK PATEL
  • - , Korea (South) HYEYOUNG CHOI
  • - CH de la Cote Basque , France PAUL ARDILOUZE
  • - McGill University Health Center , Canada Alexandre Semionov
  • - IRSA LA ROCHELLE , France JEAN LUC BIGOT
  • - The University of Tokyo Hospital , Japan MOTO NAKAYA
  • - Kyeongpook National University Hospital , Korea (South) CHANGGUN KIM
  • - Samsung Medical Center , Korea (South) CHOHEE KIM
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Scans world , India PHILSON JOSEPH MUKKADA
  • - DELTA CARE HOSPITAL, THANJAVUR, INDIA , India SIVARAJA SUBRAMANIAM
  • - St. Lukes International Hospital , Japan DAISUKE YAMADA
  • - , Korea (South) JIN YOUNG LEE
  • - Cabinet Capricorne, clinique sainte-clotilde , Reunion FABIEN HO
  • - Hamamatsu University Hospital , Japan HAYATO NOZAWA
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Narayana Multispeciality Hospital Jaipur Rajasthan , India JAINENDRA JAIN
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Konkuk University Medical Center , Korea (South) JI HEE KANG
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Chonbuk National University Hospital , Korea (South) YOUNGKWANG LEE
  • - , Korea (South) CHAEHUN LIM
  • - Soonchunhyang University Hospital Bucheon , Korea (South) SEONGHWAN BYUN
  • - University of Tsukuba Hospital , Japan HIROAKI TAKAHASHI
  • - Osaka City General Hospital , Japan SHU MATSUSHITA
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Dae Jin Medical Center , Korea (South) JIYOUNG CHOI
  • - Other , Korea (South) MINSU KIM
  • - Ajou University Hospital , Korea (South) HYERIN KIM
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - Asan Medical Center , Korea (South) JIHOON KIM
  • - Seoul Veterans Hospital , Korea (South) JANG SEONG WON
  • - Chonnam National University Hospital , Korea (South) SEUNGYOON CHAE
  • - TB centre kasaragod. , India rikhy krishnan
  • - Korea University Anam Hospital , Korea (South) KYU-CHONG LEE
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Chonbuk National University Hospital , Korea (South) SOL KI KIM
  • - , Japan SOTA MASUOKA
  • - , Korea (South) CHOI SOOYOUNG
  • - Toranomon Hospital , Japan KAORU SUMIDA
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - National Center for Global Health and Medicine , Japan HIROSHI TAKUMIDA
  • - , India SUSHANT JOSHI
  • - , Japan KAZUMA TERAUCHI
  • - , Japan YUMI MAEHARA
  • - Diagnose.me (BV) / Royal Perth Hospital , Australia YURANGA WEERAKKODY
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - , Korea (South) HYUNGYU LEE
  • - Jiangsu province hospital , China WANGJIAN ZHA
▶ Correct Answer as Differential Diagnosis : 11/79,  13.9%
  • - Mayo Clinic , United States AKITOSHI INOUE
  • - Ondokuz Mayis University , Turkey CETIN CELENK
  • - Tiger Gate Hospital , Japan SHIN-ICHI CHO
  • - Sikkim Manipal Institute of Medical Sciences, Gangtok , India HARIPRASAD SUDARSAN
  • - National Center for Global Health and Medicine , Japan MASATOSHI HOTTA
  • - University of Tsukuba, Dept of Radiology , Japan MANABU MINAMI
  • - Kitano Hospital , Japan SATOSHI IKEDA
  • - University of Tsukuba Hospital , Japan SODAI HOSHIAI
  • - iran university , Iran MOHAMAD REZA AYOUBPOUR
  • - Hamamatsu University Hospital , Japan YUKI HAYASHI
  • - Chonnam National University Hwasun Hospital , Korea (South) WONGI JEONG
▶ Semi-Correct Answer : 1/79,  1.3%
  • - The University of Kyoto Hospital , Japan TOMOAKI OTANI
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