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Long-standing RA — SCE Rheumatology MCQ

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ModerateRheumatoid arthritisLong-standing RASCE Rheumatology

A 63-year-old woman with an 18-year history of nodular, RF- and anti-CCP-positive rheumatoid arthritis reports 6 months of progressive exertional breathlessness and dry cough. She has no fever, sputum production or pleuritic chest pain. Examination reveals fine end-inspiratory bibasal crackles. Her CRP is 42 mg/L. Which rheumatoid arthritis-associated pulmonary complication is most likely?

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

The most likely diagnosis is rheumatoid arthritis-associated interstitial lung disease. The progressive dry cough and exertional breathlessness with fine bibasal inspiratory crackles indicate parenchymal interstitial disease. Older age, long disease duration, high anti-CCP titres and ongoing systemic inflammation further increase the likelihood of RA-ILD. Because she is symptomatic, this represents investigation of suspected disease rather than screening of an asymptomatic patient. Rheumatoid pleuritis more typically causes pleuritic pain or an effusion. Bronchiectasis usually produces chronic sputum and recurrent respiratory infections, while obliterative bronchiolitis causes obstructive symptoms and physiology, often with wheeze. Rheumatoid pulmonary nodules are commonly incidental and do not usually produce this diffuse basal clinical pattern.

Reference: Cornwall and Isles of Scilly NHS, Interstitial Lung Disease clinical referral criteria, reviewed 16 March 2025. https://rms.cornwall.nhs.uk/primary_care_clinical_referral_criteria/primary_care_clinical_referral_criteria/respiratory/interstitial_lung_disease