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A sixty-two-year-old white woman with a 14.5 cm (145 mm) silent giant left atrial enlargement secondary probably to rheumatic heart disease is presented. Aside from mild progressive shortness of breath during the past year, the patient had been asymptomatic all her life. Her clinical picture was manifested for the first time by syncope secondary to slow atrial fibrillation, for which a permanent pacemaker was required. The correct diagnosis of the enlarged chamber was not possible through the routine chest roentgenogram. In this case, the echocardiogram, nuclear angiogram, and computed tomography were the pertinent studies needed to reach the diagnosis.

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BackgroundRheumatoid arthritis (RA) may associate with Interstitial Lung Disease (ILD). Disease-modifying anti-rheumatic drug (DMARD) or TNF alfa inhibitors (iTNF), had been involved in the ILD development as well as exacerbation of an existing one. Nowadays there is no consensus related to treatment.ObjectivesThe aimed of this study is to evaluate efficacy and safety of Abatacept (ABA) treatment in patients with AR and ILD.MethodsMulticentre study in patients with RA and ILD associated were treated with ABA. ILD was diagnosed by High Resolution Computed Tomography (HRCT). ABA was used at dose of 10 mg/kg/4 weeks iv or 125 mg/week sc. Its efficacy was evaluated according to the following measures:a) Dyspnea classified by the Modified Medical Research Council (MMRC); Significant variability of 1 point and asymptomatic MMRC=0;b) Pulmonary function test (PFT); Significant oscillations >10% in Forced Vital Capacity (FVC) and diffusing capacity of the lung for carbon monoxide (DLCO) >10%;c) Imaging technique (HRCT);d) Joint assessment (DAS28).Quantitative variables were expressed as mean ± SD or as median (interquartile range) and compared with (Wilcoxon test) (Test Fisher) between the baseline and 3, 6 and 12 months.Results34 individuals were included (19 women /15 men), patients with ILD associated to RA, with a mean age of 61,4 ± 9,8 years. The median duration of RA before ADA was initiated was 4,8 [0,86–13,12] (0–25) years, and had previously received an average 1,29±0,90 DMARDs. RA was seropositive in 24 cases (71%). ILD was associated with a DMARD: MTX (n=3), Etanercept (n=3), Adalimumab (n=3) y Certolizumab (n=1).ABA was used in monotherapy in 14 patients and combined with other immunosuppressors in 20 patients: Leflunomide (LFD) (n=7), LFD and cyclosporine (n=1), Sulfasalazine (n=1), MTX (n=2), MTX with LFD (n=1), hydroxychloroquine (n=5), Hydroxychloroquine with LFD (n=2), Azathioprine (n=1).A significant improvement of dyspnea was observed; patients who didn't have dyspnea, kept asymptomatic. FVC and HRCT showed a significant improvement during 6 to 12 months period. DLCO remained stable in the majority of the patients. RA (DAS28) activity also improved.After follow up of 12,82±7,48 months, the most significant adverse effects were: pulmonary Infection (n=2), urinary infections (n=1), infusion reactions (n=1).ABA was discontinued due to: Serious infections (n=2); join inefficacy (n=2), pulmonary inefficacy (n=1), infusion reaction (n=1).ConclusionsABA seems to be an effective and relatively safe treatment in patients with RA and associated ILD. This data should be verified again in prospective and randomized studies.Disclosure of InterestNone declared