Cavitary Necrobiotic Nodule Imitating Malignant Lung Disease in a Patient Without Articular Manifestations of Rheumatoid Arthritis

Abstract

Pulmonary involvement is a serious complication of rheumatoid arthritis (RA) and may be seen as airway disease, rheumatoid nodules, interstitial lung disease, and pleurisy. However, cavitary rheumatoid nodules without articular manifestations are rare. We describe a male patient presenting with pleurisy and multiple rheumatoid necrobiotic nodules in the absence of arthritis or subcutaneous nodules. One of the nodules was quite large (5 x 8 cm in diameter) and cavitary, imitating bronchial carcinoma radiologically and bronchoscopically. Definite histopathologic diagnosis was obtained by open lung biopsy. The patient was given methylprednisolone and methotrexate, and significant regression was observed in clinical and radiologic findings. He has been followed for 14 months with no articular manifestations yet, receiving 4 mg/d methylprednisolone and 20 mg/wk methotrexate. The diagnosis of rheumatoid pulmonary involvement without articular manifestations can be difficult. Rheumatoid nodules may imitate bronchial carcinoma, or bronchial carcinoma may coexist in RA patients. Open lung biopsy may be necessary for differential diagnosis of pulmonary lesions in RA.

A rheumatoid nodule in an unusual location: mediastinal lymph node

“…The differential diagnosis of lung nodules with mediastinal lymph nodes would include infections such as tuberculosis and fungual, sarcoidosis, septic emboli such as endocarditis, malignancies including lymphoma or metastatic cancer, lymphomatoid granulomatosis, vasculitides such as granulomatosis with polyangiitis, amyloidosis, drug reactions and rheumatoid nodules 2 8 11. Therefore, histopathological confirmation is usually necessary.…”

Diagnóstico diferencial de nódulos pulmonares cavitados: a propósito de un caso clínico

“…El síndrome de Churg-Strauss habitualmente se manifiesta con compromiso pulmonar micronodular y rara vez se cavita 2,7 . Se han descrito lesiones cavitadas en otras enfermedades como la amiloidosis primaria, la espondilitis anquilosante, la artritis reumatoídea, la poliarteritis nodosa y el lupus eritematoso sistémico, siempre bajo la consideración de la posibilidad de etiología infecciosa en estos pacientes, generalmente sometidos a terapias inmunosupresoras por largo tiempo 2,[8][9][10][11] . En relación a la artritis reumatoídea, es importante destacar que existen varios reportes que indican un aumento de nódulos pulmonares reumatoídeos, algunas veces cavitados, en pacientes con terapia con antiTNF alfa [12][13][14] .…”

Formation of multiple pulmonary nodules during treatment with leflunomide

“…Pulmonary involvement is a severe complication of RA and can manifest as upper airway disease, interstitial lung disease, pleural effusion, bronchiolitis obliterans, fibrosing alveolitis, pulmonary rheumatoid nodules, bronchiectasis, Caplan syndrome, pulmonary hemorrhage, organizing pneumonia, vasculitis, and pulmonary infections. ( 6 - 9 )…”

“…O envolvimento pulmonar é uma complicação grave da AR e pode se manifestar como uma doença das vias aéreas superiores, doença intersticial pulmonar, derrame pleural, bronquiolite obliterante, alveolite fibrosante, nódulos reumatoides pulmonares, bronquiectasia, síndrome de Caplan, hemorragia pulmonar, pneumonia em organização, vasculites e infecções pulmonares. ( 6 - 9 )…”