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Imaging Sciences Interesting Cases

Case 134

Wade Hedegard, MD

Clinical Presentation: Patient is a 68-year-old asymptomatic male with a history of tobacco use and rheumatoid arthritis.

Imaging Findings: Chest x-ray shows an ill-defined 3.5 cm focal mass-like opacity in the right lower lung field. There are also ill-defined areas of increased opacity over the medial right lung apex and right costophrenic angle. Right-sided pleural thickening is also noted.
Figure 1. Chest x-ray shows multiple right-sided pulmonary nodules and pleural thickening.

Diagnosis: Rheumatoid Lung Nodules

Discussion: Rheumatoid lung is found in 2-54% of patients with rheumatoid arthritis (RA), often presenting before the joint manifestations. The most common pulmonary presentation of RA is interstitial pneumonia and fibrosis with histology showing either nonspecific interstitial pneumonia ( NSIP) or usual interstitial pneumonia (UIP). There are a variety of other findings including pleural effusion and/or thickening, vasculitis, lymphoid hyperplasia, BOOP and rarely nodules. CT is helpful in identifying the predominant pattern. Rheumatoid lung nodules may be seen with any of these patterns. These necrobiotic nodules may appear and disappear, similar to rheumatoid subcutaneous nodules. They range in size from a few millimeters up to 5 cm or more and are usually peripherally located. The nature of the nodules cannot be determined based solely on clinical or radiographic findings, therefore a lung biopsy is required. The differential diagnosis for pulmonary nodules in a patient with rheumatoid arthritis includes rheumatoid nodules, bronchogenic carcinoma, infectious nodules and lymphoma among other etiologies.

References:

  1. Patil AK, Hegde KK. Rheumatoid arthritis-related lung disease--a case report. Indian J Radiol Imaging 2006;16:853-5.
  2. Tanaka N, Kim JS, Newell JD, et al. Rheumatoid arthritis-related lung diseases: CT findings. Radiology. 2004 Jul;232(1):81-91. [PubMed]
  3. Webb WR, Higgins CB. Thoracic Imaging. Lippincott, Williams and Wilkins. Philadelphia, 2005:425-428.