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BACKGROUNDRheumatoid arthritis is an autoimmune, chronic and systemic disease with no defined etiology, that primarily affects synovial joints. Lung and pleura are also common sites of extraarticular involvement. Manifestation of interstitial lung disease on RA-onset is a major concern due to its potential seriousness and therapeutic challenge. CASE REPORTA 51-year-old female, started in August 2020 with dyspnea (mMRC class IV), and sought care in an emergency room. The diagnostic suspicion was SARS-CoV-2 virus infection . Despite having a negative molecular test, a chest tomography was performed and showed multiple ground-glass opacifications. The patient remained hospitalized for a few days and after being discharged from hospital, she maintained severe dyspnea and started with intense myalgia and weakness in the shoulder girdle, being referred by the internal medicine team for rheumatologic evaluation. In the first evaluation, the diagnostic hypothesis of polymyalgia rheumatica was raised, with high-dose prednisone being prescribed and initial diagnostic work up. The patient returned with lab test results that showed positive rheumatoid factor and ACPA (116.2 and 5.9, respectively), in addition to having developed arthritis in some proximal interphalangeal joints, then was established the diagnose of rheumat id arthritis with interstitial lung disease. Treatment with methotrexate was started; however, after 2 months the patient had worsened lung function. A comprehensive review of the literature was carried out and it was decided to start treatment with rituximab, with good therapeutic response. CONCLUSIONThe best treatment for interstitial lung disease secondary to rheumatoid arthritis is yet to be established. Drug pneumotoxicity raises concern, but current evidence suggests a protector factor in RA patients submitted to methotrexate treatment. Some studies show that the use of glucocorticoids and other biologic or synthetic DMARDs can be beneficial, especially in young patients with usual interstitial pneumonia and symptomatic patients. In an article published in 2020 in Rheumatology, it was concluded that patients with interstitial lung disease who were treated with rituximab apparently had lower mortality rates compared to patients treated with anti-TNF, although the difference did not reach statistical significance.

BACKGROUNDIn the etiological investigation of cavitated pulmonary nodules, special attention should be paid to the possibility that these correspond to the pulmonary manifestation of systemic granulomatous diseases. Among those of infectious etiology, tuberculosis and systemic mycoses, such as histoplasmosis and paracoccidioidomycosis, stand out. Among those of inflammatory etiology, sarcoidosis and granulomatosis with polyangiitis should be remembered. The presence of systemic disease, with constitutional symptoms and involvement of other organs, increases the probability of having one of these causes. CASE REPORTA 60-year-old male, paving technician, was hospitalized for investigation of dry cough, progressive dyspnea, weight loss and fever that had started 40 days ago. Laboratory tests with altered acute phase tests, chest X-ray with sparse consolidations. Antibiotic therapy with ceftriaxone was started and chest computed tomography was performed, which showed the presence of multiple solid nodules with irregular contours, some cavitated, diffuse and confluent in both lungs. TRM-TB undetectable; PPD, serology for hepatitis, HIV and HTLV nonreactive. In consultation with the Rheumatology team, assistance in differential diagnosis was requested. The patient was in good general condition, without involvement of other organs, ANA reagent homogeneous nucleolar pattern with negative fractionation, negative ANCA, facial sinus tomography without alterations. He referred to a recent stay in "Zona da Mata", in the state of Minas Gerais for work. A suspicion of systemic mycosis was raised, bronchoalveolar lavage was performed, with bacterial culture without growth, negative AFB, negative fungal investigation, oncotic cytology with absence of neoplastic cells, anatomopathological evidence showing a mild nonspecific chronic inflammatory process and focal squamous metaplasia. Extended propaedeutic, with segmentectomy for lung biopsy. Macroscopically, the lung surface was irregular, with a hardened and multinodular consistency on palpation diffusely. Pathology with findings compatible with pulmonary paracoccidioidomycosis-Paracoccidioides brasiliensis. Treatment with itraconazole was initiated and referred to the infectiology outpatient clinic for follow-up. CONCLUSIONAs seen in the case report above, in the care of patients who present with constitutional symptoms associated with nodular pulmonary involvement, it is important for the medical team to have high suspicion for granulomatous diseases, especially if the epidemiology is compatible. These mimic each other, making the differential diagnosis difficult, often requiring extensive propaedeutic.