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Rheumatoid lung disease — SCE Rheumatology MCQ

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EasyRheumatoid arthritisRheumatoid lung diseaseSCE Rheumatology

A 64-year-old woman with poorly controlled rheumatoid arthritis has taken a stable dose of methotrexate for 5 years. She develops gradually progressive exertional breathlessness over 6 months without fever. Examination shows fine bibasal inspiratory crackles and an oxygen saturation of 94% on air. HRCT demonstrates basal, subpleural reticulation with traction bronchiectasis. What is the most likely diagnosis?

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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 usual interstitial pneumonia-type pattern. The discriminating features are the chronic progressive breathlessness, fine bibasal crackles and basal subpleural reticulation with traction bronchiectasis. Methotrexate pneumonitis is usually an acute or subacute febrile respiratory illness, commonly with diffuse ground-glass or NSIP-type abnormalities rather than established basal fibrotic change. Organising pneumonia more typically produces patchy peripheral or peribronchovascular consolidation. Pulmonary embolism does not explain the chronic fibrotic HRCT pattern, while cardiac failure would be expected to cause features such as septal oedema, pleural effusions or cardiomegaly rather than traction bronchiectasis.

Reference: Laria A et al. Interstitial Lung Disease in Rheumatoid Arthritis: A Practical Review, Figure 3, 2022. https://pubmed.ncbi.nlm.nih.gov/35646974/