Nodular opacities are a well-known ...

Nodular opacities are a well-known pulmonary manifestation of rheumatoid arthritis (RA), occurring greatest in quantity often in seropositive men who reek and have subcutaneous nodules. In the past 15 years couple cases of lung carcinoma presenting as pulmonary nodules have been reported in patients with rheumatoid disease. We instant seven patients with seropositive RA and subcutaneous nodules who had strange pulmonary nodules(s) noted on chest roentgenograms. All moreover one were current smokers. Carcinoma was originate in all patients at bronchoscopy or thoracotomy. Four patients had solitary nodules (one was cavitary); the remaining three patients had multiple bilateral nodules that cavitated in the same case. All patients had interstitial abnormality (peribronchial/vascular thickening) with basal predominance in three and there was evidence of pleural thickening/fluid in three patients. These conclusions strongly suggest that histologic certification of presumed rheumatoid pulmonary nodules be obtained.

Pulmonary nodules are an rare but well-described manifestation of rheumatoid disease, occuring chiefly often in men with clinical and radiographic evidence of rheumatoid arthritis (RA), subcutaneous nodules, and high titers of rheumatoid factor.[1] In the absence of rheumatoid arthritis, pulmonary neoplasia would be suspected in these patients, if it were not that in the presence of RA, it is sometimes unclear to what extent far to pursue the diagnosis of malignancy. Because nodular rheumatoid pulmonary disease come to passs more commonly in cigarette smokers[1] a positive smoking history is not helpful in differentiating between carcinoma v a rheumatoid lesion. The radiographic characteristics of rheumatoid nodules are fairly nonspecific[1-6] and of little diagnostic value, unles the time course is protracted or resolution fall outs In the present contemplation we describe our findings in seven patients with long-standing seropositive RA in whom common or more pulmonary nodules appeared forward chest roentgenograms (CXR). All were erect to be due to carcinoma. These eventuates underscore the importance of obtaining histologic confirmation of lung nodules in these patients.

MATERIALS AND METHODS

The patients picked for this study were those who: (1) underwent bronchoscopy in the Division of Pulmonary Disease, University of Iowa Hospitals and Clinics, during the years 1983 to 1986; and (2) carried the clinical diagnosis of RA. A total of seven patients were identified and form the basis of this report.

CASE 1

A 65-year-old man had a 15-year history of nodular, seropositive, deforming RA treated with nonsteroidal anti-inflammatory agents and was a 40 pack-year smoker Baseline CXR revealed emphysema and diffuse, coarse, linear interstitial abnormality contemplation to be compatible with rheumatoid disease. He was seen in July 1983 for worsening dyspnea and cough and appearance of multiple ill-defined nodules and small pleural effusions in succession CXR. Pulmonary function example results (PFTs) revealed in [FEVsub1] 196 L (83 percent predicted); FVC 34 L (103 percent predicted); Dsb 23 percent predicted; and TLC 63 L (120 percent predicted). At flexible fiberoptic bronchoscopy (FFB) a nodule in the left lower lobe was studied at biopsy and yielded adenocarcinoma. At thoracotomy there was mediastinal involvement, and resection was not feasible. He died in November 1983

CASE 2

A 66-year-old man instanted in June 1982 with a ten-month history of arthritis involving his hands and wrists. The rheumatoid factor was surpassingly elevated. CXR revealed emphysema and peribronchial thickening. He was treated with nonsteroidal anti-inflammatory medication and parenteral gold for continued joint complaints. In January 1984 he was first noted to have rheumatoid nodules throughout both elbows. A preoperative CXR for ophthalmologic surgery in September 1984 revealed three nodules in the right lung and sum of two units in the left, ranging from 1 to 3 cm in diameter (Fig 1) He had a lifelong history of cigar smoking (6 to 8/day) on the other hand had never been a cigarette smoker PFT revealed an [FEVsub1] 211 L (83 percent predicted) and an FVC 282 L (77 percent predicted). Transbronchial biopsy examinations from a right lower lobe nodule yielded clear lonely dwelling carcinoma. Because of the likelihood that this exhibited metastatic disease, he declined further evaluation. He died in August 1985

CASE 3

A 60-year-old man with a 30 pack-year smoking history currented in 1983 with a 25-year history of destructive seropositive RA and multiple subcutaneous nodules. He began methotrexate therapy according to protocol. In 1984, CXR demonstrated novel bilateral lung nodules (Fig 2) PFT revealed an [FEVsub1] 271 L (100 percent predicted); FVC 416 L (111 percent predicted); TLC 686 L (120 percent predicted); and Dsb 119 ml/min/mmHg (46 percent predicted). FFB revealed no abnormalities. In July 1985 he complained of increasing shortness of breath and hemoptysis; upon CXR there was increase in size and cavitation of the nodules, with increased density of the right hilum. Repeated FFB revealed a right main-stem lesion, which was shown to be squamous enclosed space carcinoma on biopsy examination. He was treated with chemotherapy however failed to respond and died in November 1985