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RA Pulmonary Nodules — SCE Rheumatology MCQ

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ModerateRheumatoid ArthritisRA Pulmonary NodulesSCE Rheumatology

A 55-year-old woman with seropositive rheumatoid arthritis and subcutaneous rheumatoid nodules is taking methotrexate. A chest radiograph obtained for a persistent cough shows several new bilateral pulmonary nodules, one of which is cavitating. Which group of diagnoses must be actively considered before the lesions are attributed to rheumatoid arthritis?

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Correct answer: B — Rheumatoid pulmonary nodules or accelerated nodulosis; infection; primary or metastatic malignancy; granulomatosis with polyangiitis

The correct answer is B. Multiple peripheral or subpleural nodules, sometimes with cavitation, are a recognised extra-articular manifestation of rheumatoid arthritis, and methotrexate may accelerate rheumatoid nodulosis. However, neither established subcutaneous nodules nor cavitation proves a rheumatoid cause. Mycobacterial, fungal and bacterial infection, primary or metastatic malignancy, and granulomatosis with polyangiitis must be excluded. Methotrexate pneumonitis and rheumatoid interstitial lung disease usually produce diffuse interstitial, ground-glass or fibrotic abnormalities rather than discrete cavitating nodules, making B inappropriate. The disorders in C may cause pulmonary abnormalities but do not represent the essential high-priority differential in this clinical context. Benign lesions in D must not be presumed when nodules are new and cavitating, while the RA manifestations in E have different radiological patterns.

Reference: BMJ Case Reports, “Rheumatoid arthritis with necrotic lung nodules”, 2020. https://pubmed.ncbi.nlm.nih.gov/32936111/