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RA-Associated ILD — SCE Rheumatology MCQ

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HardRheumatoid ArthritisRA-Associated ILDSCE Rheumatology

A 44-year-old woman with strongly anti-CCP-positive rheumatoid arthritis has a 10-month history of progressive dry cough and exertional dyspnoea. Her arthritis is clinically quiescent on a stable weekly dose of methotrexate, which she has taken for 8 years. She is afebrile and her C-reactive protein is normal. HRCT demonstrates basal, subpleural reticulation with traction bronchiectasis and honeycombing, without predominant ground-glass opacity. Pulmonary function tests show FVC 62% predicted and DLCO 48% predicted. Which diagnosis best accounts for these findings?

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Correct answer: A — Rheumatoid arthritis-associated interstitial lung disease

The diagnosis is rheumatoid arthritis-associated interstitial lung disease (RA-ILD), with a fibrotic UIP pattern. The decisive features are the 10-month progressive course, reduced FVC and DLCO, and basal subpleural traction bronchiectasis with honeycombing. UIP is a recognised common radiological pattern in RA-ILD, and high-titre anti-CCP supports this extra-articular association. Methotrexate pneumonitis remains an important differential but is usually acute or subacute, often with fever, dry cough and an NSIP-like ground-glass pattern rather than established UIP-pattern fibrosis. Pneumocystis pneumonia would usually produce an acute hypoxic illness with diffuse ground-glass change. Bronchiectasis alone does not explain the restrictive physiology or honeycombing. Idiopathic pulmonary fibrosis is inappropriate because a recognised underlying connective-tissue disease is present.

Reference: Fragoulis GE, Nikiphorou E, Larsen J, Korsten P, Conway R. Methotrexate-Associated Pneumonitis and Rheumatoid Arthritis-Interstitial Lung Disease: Current Concepts for the Diagnosis and Treatment. Frontiers in Medicine, 2019. https://pubmed.ncbi.nlm.nih.gov/31709258/