ISPUB.com / IJPM/8/2/13209
  • Author/Editor Login
  • Registration
  • Facebook
  • Google Plus

ISPUB.com

Internet
Scientific
Publications

  • Home
  • Journals
  • Latest Articles
  • Disclaimers
  • Article Submissions
  • Contact
  • Help
  • The Internet Journal of Pulmonary Medicine
  • Volume 8
  • Number 2

Original Article

Pleuropulmonary manifestations in rheumatoid arthritis

R Prasad, S Kant, R Garg, S Verma, Sanjay, S Das

Keywords

bronchiolitis obliterans organizing pneumonia, interstitial lung disease, pleuropulmonary, rheumatoid arthritis, usual intestitial pneumonia

Citation

R Prasad, S Kant, R Garg, S Verma, Sanjay, S Das. Pleuropulmonary manifestations in rheumatoid arthritis. The Internet Journal of Pulmonary Medicine. 2006 Volume 8 Number 2.

Abstract


Background: Pleuropulmonary manifestations of rheumatoid arthritis are a frequent extra-articular manifestation of rheumatoid arthritis (RA). Various studies have reported a prevalence of interstitial lung disease (ILD) of 5-40 %.

Objectives: To find out the pattern of pleuropulmonary manifestations and to assess the spirometric and radiological changes of lung diseases in RA, in patients admitted to a respiratory unit.

Duration of study: July 2003 to August 2006


Methods: The study was conducted on 17 patients with Rheumatoid arthritis (previously diagnosed), who were admitted for various respiratory complaints, in the Department of Pulmonary Medicine, King George's Medical University. A thorough respiratory evaluation was done including Clinical evaluation for signs and symptoms, Chest x-ray PA view, HRCT Thorax, Spirometry and sputum for AFB.

Results: 17 patients with rheumatoid arthritis were evaluated for pleuropulmonary manifestations. The male & female ratio was 1.4:1; The Mean age was 52.6 years (18-66). ILD was the most common pulmonary manifestation of rheumatoid arthritis and as noted in 88.2 % of patients. Most common type was Usual Interstitial Pneumonia (UIP), Bronchiolitis obliterans organizing pneumonia (BOOP) was seen in only 2 patients. Dyspnoea was the most common presenting symptom of ILD. Pleural effusion was noted in 11.8 % of patients. Spirometry showed a restrictive pattern in 52.9 % (i.e.9/17), obstructive pattern in 11.8 % (i.e.2/17) and six were unable to cooperate. Interstitial lung disease (ILD) was seen more in men.

Conclusion: The study showed that an interstitial lung disease (ILD) was the most common pleuropulmonary manifestations in RA patients.

 

Introduction

Rheumatoid arthritis is a chronic systemic inflammatory disorder that may affect many tissue organs –skin, blood vessels, heart, lungs, and muscles but principally affect joints, producing a non suppurative synovitis that often progress to tissue destruction of articular cartilage and ankylosis of joints 2,3. The prevalence of Rheumatoid arthritis is approximately 0.8% of the population (range 0.3 to 2.1%) but in India it is exactly not known. Women are affected three times more than men. Rheumatoid arthritis usually appears during 3rd to 5 th decades of life. Their prevalence increases with age. While pleuro-pulmonary manifestations are more likely to be observed in males. The most common lung manifestation is pulmonary fibrosis followed by Pleuritis, Pleural effusion, pulmonary nodules, pulmonary hypertension, and progressive loss of lung volume, secondary amyloidosis, sclerosing mediastinitis and bronchocentric granulomatosis in decreasing order.

Method

During the intake period of 3 year from July 2003 to august 2006, 17 patients of rheumatoid arthritis admitted to the Department of Pulmonary Medicine were evaluated for pleuro-pulmonary manifestations. All patients were classified as rheumatoid arthritis on the basis of American Rheumatism Association 1987 revised classification criteria1, complete blood counts, C - reactive protein (CRP), serum rheumatoid factor and X-ray Hand & wrist, were done for all patients. Evaluations for pleuro-pulmonary manifestation were done by Chest x-ray PA view, Spirometry and High resolution computerized tomography (HRCT) of thorax. Sputum for AFB was done on three consecutive days in all patients to exclude tuberculosis.

Result

Of the 17 patients with rheumatoid arthritis, 10 were males while 7 were females (Ratio M: F; 1.4:1). The mean age of study group were 52.6 years (Range 18-66). Mean duration of rheumatoid arthritis was 11.9 years. Mean duration of respiratory complaints was 10.3 months (Range 2-14 months). Dyspnoea and dry cough were most common presenting symptoms (76.47 %). Sputum for AFB was negative in all patients. Others system were with in normal limits. Spirometry showed restrictive pattern in 52.9 % cases (Mean FEV1/FVC 86 % and Mean FVC 1.16 Litre) and obstructive pattern noted in 11.8 % while 6 (35.3 %) patients did not cooperate. (Table 1: Shows patient's characteristics of study group).

Figure 1
Table 1

Interstitial lung disease was the most common Pleuro-pulmonary disease pattern being present in 15 patients (88.2 %). Among Interstitial lung disease (ILD), Usual Interstitial Pneumonia (UIP) was most common pattern noted in 13 (88.7 %), followed by Bronchiolitis obliterans organizing pneumonia (BOOP) in 2 (13.33 %). Pleural effusion was observed in 2 (11.8 %) of all patients. (Table 2: Showing pleuro-pulmonary abnormality seen on HRCT Thorax).

Figure 2
Table 2

Discussion

It is now known that Interstitial Lung Disease is both the most common and most serious pleuro-pulmonary complication of rheumatoid arthritis4. Ellman and Ball first noted the association between pulmonary fibrosis and rheumatoid arthritis in 19485.

ILD is a relatively common complication in RA being reported in 19-44% in four prospective studies6,7,8,9. Generally two patterns of Interstitial Lung Disease are more common amongst RA, Usual Interstitial Pneumonia (UIP) and Bronchiolitis obliterans organizing pneumonia (BOOP). These patients have complaints of breathlessness and dry cough. Physical examination reveals bibasilar crepts. Chest x-ray shows interstitial infiltrates mostly basal and in peripheral parts of lungs. HRCT Thorax is characteristic in Usual Intestitial Pneumonia (UIP) and is characterized by presence of reticular opacity predominatly in the subpleural regions of lung bases and often associated with cystic air spaces measuring 2 to 20 mm (honey combing)10,11,12. Disease activity is characterized by presence of patchy areas of hazy increased density (Ground glass opacity) 13. While Bronchiolitis obliterans organizing pneumonia (BOOP) is characterized by patchy unilateral or bilateral air space consolidation14.

Pleuritis is reported in 21 % cases. Pleural effusion is occasional manifestation being reported in 3-5% of cases in different studies15. The patients are usually asymptomatic but sometimes complicated by severe pluritic pain, fever, breathlessness. Pleural effusion is usually small and unilateral but may be large and bilateral. Pleural fluid is characteristic and shows exudative type (protein usually >3.0gm/dl), low sugar (<50 mg/dl) in about 75% of patients, raised LDH, raised cholesterol and high Titer of RF 16,17. Another typical abnormality is high pleural fluid/blood ratio of neuron specific enolase, rising 10 or more times 18.

Others less common pleuro-pulmonary manifestations of rheumatoid arthritis are rheumatic nodules 19, Caplan's syndrome 20, upper zone fibrosis and cavitation, upper airway obstruction occasionally resulting into stridor21 and Obstructive sleep apnoea as well as Central sleep apnoea. Others rare lung manifestation of rheumatoid arthritis are, Pulmonary hypertension22, progressive loss of lung volume due to diapharagmatic dysfunction23, secondary amyloidosis24, sclerosing mediastinitis25 and bronchocentric granulomatosis26 .

The present study has shown that Interstitial Lung Disease, predominantly usual interstitial pneumonia (UIP) is the most common pleuropulmonary manifestation in Rheumatoid arthritis patients.

Correspondence to

Dr. R.Prasad M.D., FAMS Professor & Head Department of Pulmonary Medicine C.S.M. Medical University,UP, Lucknow, India-226003 E-mail: rprasad2@sancharnet.in rprasad2@rediffmail.com Phone: 0522-2255167 FAX: 0522-2255167

References

1. Arnett FCS, Edworthy M, Bloch DA, et al. The American Rheumatism Association Revised Criteria for the classification of RA. Arthritis Rheum 1988; 32:315-24.
2. Eisenberg H. Interstitial lung diseases associated with collagen vascular disorder. Clin Chest Med 1982; 3:565
3. Hunnighake GW, Frauci AS. Pulmonary involvement in collagen vascular diseases. Am Rev Respir Dis 1979; 119:471
4. Roschmann RA,Rothenberg RJ.pulmonary fibrosis in RA.A review of clinical features and therapy.Semin Arthritis Rheum 1987;16:174-85
5. Ellmann P,Ball RE.Rheumatoid disease with joint and pulmonary manifestations.BMJ 1948;2:816-20.
6. Fewins HE, McGowan I, Whitehouse GH,et al. High definition computed tomography in rheumatoid arthritis associated pulmonary disease. Br J Rheumatol 1991; 30:214-6.
7. Gabby E,Tarala R,Will R,et al. Interstitial lung disease in recent onset rheumatoid arthritis. Am J Respir Crit Care Med 1997; 156:528-35.
8. Mc Donagh J,Greaves M,Wright AR, et al. High resolution tomography of the lungs in patients with rheumatoid arthritis and interstitial lung disease. Br J Rheumatol 1994; 33:118-22.
9. Cortet B, Perez T, Roux N, et al. pulmonary function tests and High resolution tomography of the lungs in patients with rheumatoid arthritis. Ann Rheum Dis 1997; 56:596-600.
10. Mathieson JR,Mayo JR,Staple CA, et al: Chronic diffuse infiltrative lung disease : comparison of diagnostic accuracy of CT and chest radiography. Radiology 1989; 117: 111-116.
11. Muller NL, Miller RR,Webb WR, et al. Fibrosing alveolitis: CT-pathologic correlation. Radiology 1986; 160: 585-588.
12. Strickland B, Strickland NH: The value of high definition, narrow section computed tomography in Fibrosing alveolitis . Clin Radiol 1988; 39:589-594.
13. Muller NL, Staples CA, Miller RR, et al. Disease activity in idiopathic pulmonary fibrosis: Computed tomographic-pathologic correlation. Radiology 1987; 165: 731-734.
14. Muller NL, Staples CA, Miller RR, et al. Bronchiolitis obliterans organizing pneumonia: CT features in 14 patients. Am J Roentgenol 1990;154:983-987.
15. Walker WG, Wright V. Rheumatoid Pleuritis. Ann Rheum Dis 1967; 26:467.
16. Popper MS, Bogdonof ML, HughesRL. Interstitial rheumatoid lung disease: a reassessment and review of literature.Chest 1972;62:243
17. Dodson WH, Hollingsworh JW. Pleural effusion in rheumatoid arthritis. Impaired transport of glucose. N Eng J Med 1966; 275:1337
18. Nyberg P, Soderbolm T, Petterson T, Linko L. Neuron specific enolase in pleural effusion in patients with rheumatoid pleural effusion.Thorax 1996;51:92
19. Walker WC,Wright V: Pulmonary lesions and rheumatoid arthritis. Medicine 1968; 47:501-520
20. Caplan A: Certain unusual radiographic appearances in the chest of coal miners suffering from rheumatoid arthritis. Thorax 1953; 8:19-37.
21. Geddes DM,Corrin B,Brewerton DA,et al. Progressive airway obliteration in adults and its association with rheumatoid disease. Q J Med 1977; 46:427-444.
22. Gardner DL, Duthie JJR, Mc Leod J, Allan WSA. Pulmonary hypertension in rheumatoid arthritis. Report of case with intimal sclerosis of the pulmonary and digital arteries. Scott Med J 1957; 2:183.
23. Macfarlane JD, Dieppe PA, Rigden BG, Clark TJH. Pulmonary and pleural lesions in rheumatoid arthritis. Br J Dis Chest 1978; 73:288.
24. Tribe CR. Amyloidosis in rheumatoid arthritis.Mod Trends Rheumatol 1966; 1:121.
25. Mole TM, Glover J, Sheppard MN. Sclerosis mediastinitis: a report on 18 cases. Thorax 1995; 50:280.
26. Hellem SO, Kanner RE, Renzetti AD. Bronchocentric granulomatosis associated with seropositive polyarthritis. Chest 1983; 83:831.

Author Information

R. Prasad
Professor & Head, Department of Pulmonary Medicine, Chatrapati Sahuji Maharaj(CSM) Medical University

Surya Kant
Professor, Department of Pulmonary Medicine, Chatrapati Sahuji Maharaj(CSM) Medical University

Rajiv Garg
Assistant Professor & Head, Department of Pulmonary Medicine, Chatrapati Sahuji Maharaj(CSM) Medical University

Sanjay Kumar Verma
Senior Resident, Department of Pulmonary Medicine, Chatrapati Sahuji Maharaj(CSM) Medical University

Sanjay
Junior Resident, Department of Pulmonary Medicine, Chatrapati Sahuji Maharaj(CSM) Medical University

S. Das
Professor & Head, Department of Rheumatology, Chatrapati Sahuji Maharaj(CSM) Medical University

Download PDF

Your free access to ISPUB is funded by the following advertisements:

 

BACK TO TOP
  • Facebook
  • Google Plus

© 2013 Internet Scientific Publications, LLC. All rights reserved.    UBM Medica Network Privacy Policy