INTERSTITIAL LUNG DISEASE IN SERONEGATIVE RHEUMATOID ARTHRITIS

ABSTRACT

SESSION TITLE Autoimmune Diffuse Lung Disease Case Posters SESSION TYPE Case Report Posters PRESENTED ON 10/19/2022 1245 pm - 0145 pm INTRODUCTION: Interstitial lung disease (ILD) associated with connective tissue diseases (CTD) present with varying degrees of severity and functional impairment. Patients with CTD-ILD may often initially present for pulmonary evaluation. Pulmonologists must be familiar with the spectrum of CTD syndromes, the associated serologic testing, and referral criteria to rheumatology. CASE PRESENTATION A 62-year-old never-smoking female with prior mild COVID-19 infection, previously vaccinated, presented to clinic with a diagnosis of pulmonary fibrosis. She endorsed three years of progressive shortness of breath and dyspnea on exertion walking only eight blocks and with light household chores. The patient had worked as a professional chef in poorly ventilated kitchens. Review of systems was notable for morning stiffness and pain in bilateral hand joints with associated difficulty opening medication bottles secondary to symptoms. Previous computed tomography (CT) of the chest demonstrated peripheral, subpleural, and basal predominant reticulations accompanied by bronchiectasis and bronchioloectasis consistent with probable usual interstitial pneumonia (UIP). Envisia® genomic testing was performed and results were negative for idiopathic pulmonary fibrosis. Extensive serologic testing for CTD was performed, including rheumatoid factor and anti-cyclic citrullinated peptides which were normal. The patient was referred to rheumatology, and hand x-rays demonstrated diffuse MCP joint narrowing. The patient was diagnosed with seronegative rheumatoid arthritis (RA) with RA-ILD and started on treatment. DISCUSSION: Multiple society guidelines recommend serologic testing to rule out CTD-ILD in patients with new ILD. ILD has been reported to occur in 20-60% of patients with RA with multiple patterns. Patients with seronegative RA are more likely to develop extraarticular manifestations of RA including fibrotic lung disease. Patients who are asymptomatic from RA-ILD may be monitored clinically for worsening RA-ILD. The selection of patients for treatment with an immunosuppressive agent or glucocorticoids should be done with a multidisciplinary team. Patients with RA-ILD and a UIP pattern may not respond to immunosuppressive medications but are typically trialed on treatment for worsening lung disease. Randomized controlled trials that included patients with RA-ILD with fibrosis have suggested a role for nintedanib, an anti-fibrotic agent, in slowing the progression of forced vital capacity decline. CONCLUSIONS: CTD-ILD is a common diagnosis in pulmonary clinics, and ILD symptoms may be the chief complaint at presentation. Providers must be familiar with diagnostic criteria for CTD and obtain a detailed review of systems that might suggest the diagnosis of CTD. Early diagnosis of CTD-ILD and monitoring of disease activity is important to prevent progression of CTD-ILD. Reference #1 Yoo H, Hino T, Han J, et al. Connective tissue disease-related interstitial lung disease (CTD-ILD) and interstitial lung abnormality (ILA) Evolving concept of CT findings, pathology and management. Eur J Radiol Open. 2020;8100311. Published 2020 Dec 16. doi10.1016/j.ejro.2020.100311 Reference #2 Sahatciu-Meka V, Rexhepi S, Manxhuka-Kerliu S, Rexhepi M. Extra-articular manifestations of seronegative and seropositive rheumatoid arthritis. Bosn J Basic Med Sci. 2010;10(1)26-31. doi10.17305/bjbms.2010.2729 Reference #3 Cottin V. Pragmatic prognostic approach of rheumatoid arthritis-associated interstitial lung disease. Eur Respir J. 2010 Jun;35(6)1206-8. doi 10.1183/09031936.00008610. PMID 20513909. DISCLOSURES No relevant relationships by Brenda Garcia No relevant relationships by Zein Kattih No relevant relationships by Priyanka Makkar No relevant relationships by Jonathan Moore