Rheumatoid arthritis with pulmonary accelerated rheumatoid nodules treated by baricitinib: a case-based review.

Pulmonary accelerated rheumatoid nodules (ARN) represent a rare occurrence within the context of rheumatoid arthritis (RA), with conventional treatment typically involving corticosteroids. In this report, we present a unique case of pulmonary ARN managed with baricitinib, a Janus kinase inhibitor. The patient, a 46-year-old woman diagnosed with RA, initially displayed no evident pulmonary nodules upon pulmonary imaging. Her treatment regimen encompassed corticosteroids, methotrexate, and leflunomide. Nevertheless, a chest computed tomography (CT) scan conducted after a year unveiled the presence of multiple bilateral pulmonary nodules. A thoracoscopic biopsy of these nodules confirmed the presence of rheumatoid nodules. Treatment with baricitinib, a Janus kinase inhibitor or synthetic disease-modifying antirheumatic drug (DMARD), effectively reduced the size of the nodules. Our review of 45 articles on ARN published since 1986 found that nine of them reported 13 cases of pulmonary ARN. These nodules may be caused by certain synthetic and biological DMARDs and often present with respiratory symptoms. CT scans typically reveal multiple solid nodules or ground-glass opacities, some of which may have cavities. Treatment customarily involves discontinuing the suspected drugs and administering corticosteroids. This case suggests that Janus kinase inhibitors may be an effective treatment option for ARN.

Hyoepiglottic Rheumatoid Nodule Mimicking Head and Neck Malignancy on 18 F-FDG PET/CT.

ABSTRACT: A 54-year-old man with a history of tonsillar squamous cell carcinoma treated with chemoradiotherapy and an 18-year history of seropositive rheumatoid arthritis in remission without maintenance therapy presented with right cervical pain and dysphagia for several months. Flexible laryngoscopy did not show any lesion, and MRI revealed a necrotic lesion inside the thyro-hyo-epiglottic space attached to the hyoid bone. 18 F-FDG PET/CT demonstrated a moderately increased metabolic activity of the lesion without any other suspected lesions. Surgical resection was performed, and pathology revealed a necrotizing granuloma compatible with a rheumatoid nodule.

[Rheumatoid Lung Nodule could be Diagnosed by Pulmonary Biopsy:Report of a Case].

A 60-year-old woman was referred to our department for further examination for chest abnormal shadow in the right upper lobe. She had a past history of rheumatoid arthritis. Positron emission tomography-computed tomography (PET-CT) showed mild abnormal accumulation of fluorodeoxyglucose (FDG). Because of lung cancer could not be denied, she underwent partial resection of the right upper lobe and the nodule was diagnosed as a rheumatoid nodule by pathology.

Rheumatoid lung nodules with "feeding-vessel" sign.

Rheumatoid arthritis is a systemic inflammatory disease which causes symmetric polyarthritis. Lungs are common site for extra-articular involvement. Rheumatoid lung nodules occur in about 32% of patients with rheumatoid arthritis. The appearance of a lung nodule, along with the blood vessel supplying it, is called "feeding-vessel" sign on computed tomography. It is most commonly seen in infections. However, it can also be present in metastases and pulmonary vasculitis. We describe a woman with long-standing rheumatoid arthritis with subcutaneous and pulmonary nodules. Computed tomography of the chest showed "feeding-vessel" sign. There was no evidence of infection, malignancy, or vasculitis. She was treated for rheumatoid lung nodulosis with rituximab with which she improved remarkably. To the best of our knowledge, "feeding-vessel" sign in rheumatoid lung nodules has never been reported before. This case highlights the fact that "feeding-vessel" sign is not specific for pulmonary infections. It can rarely be seen in rheumatoid lung nodulosis.

A 48-Year-Old South African Woman with Rheumatoid Arthritis and Lung Nodules.

CASE PRESENTATION: We present the case of a 48-year-old South African woman with no smoking history, and seropositive rheumatoid arthritis diagnosed in 2001. She was treated with chloroquine (150 mg, 4 times per week) and methotrexate (30 mg weekly) with well-controlled symptoms until 2015, when she developed a disease flare. Her treatment regimen was changed to leflunomide (20 mg daily) monotherapy with subsequent symptom control. Biologic agents were not accessible because of cost constraints.

Rheumatoid pulmonary nodules: clinical and imaging features compared with malignancy.

OBJECTIVES: The objective of this study was to identify clinical and imaging features that distinguish rheumatoid lung nodules from malignancy. METHODS: We conducted a retrospective review of 73 rheumatoid patients with histologically-proven rheumatoid and malignant lung nodules encountered at Mayo Clinic, Rochester, MN (2001-2016). Medical records and imaging were reviewed including a retrospective blinded review of CT and PET/CT studies. RESULTS: The study cohort had a mean age of 67 ± 11 years (range 45-86) including 44 (60%) women, 82% with a smoking history, 38% with subcutaneous rheumatoid nodules, and 78% with rheumatoid factor seropositivity. Subjects with rheumatoid lung nodules compared to malignancy were younger (59 ± 12 vs 71 ± 9 years, p < 0.001), more likely to manifest subcutaneous rheumatoid nodules (73% vs 20%, p < 0.001) and rheumatoid factor seropositivity (93% vs 68%, p = 0.034) but a history of smoking was common in both groups (p = 0.36). CT features more commonly associated with rheumatoid lung nodules compared to malignancy included multiplicity, smooth border, cavitation, satellite nodules, pleural contact, and a subpleural rind of soft tissue. Optimal sensitivity (77%) and specificity (92%) (AUC 0.85, CI 0.75-0.94) for rheumatoid lung nodule were obtained with ≥ 3 CT findings (≥ 4 nodules, peripheral location, cavitation, satellite nodules, smooth border, and subpleural rind). Key 18FDG-PET/CT features included low-level metabolism (SUVmax 2.7 ± 2 vs 7.2 ± 4.8, p = 0.007) and lack of 18F-fluorodeoxyglucose (FDG)-avid draining lymph nodes. CONCLUSION: Rheumatoid lung nodules have distinct CT and PET/CT features compared to malignancy. Patients with rheumatoid lung nodules are younger and more likely to manifest subcutaneous rheumatoid nodules and seropositivity. KEY POINTS: • Rheumatoid lung nodules have distinct clinical and imaging features compared to lung malignancy. • CT features of rheumatoid lung nodules include multiplicity, cavitation, satellite nodules, smooth border, peripheral location, and subpleural rind. • Key PET/CT features include low-level metabolism and lack of FDG-avid draining lymph nodes.

Dermatoscopy of Granulomatous Disorders.

Although diagnosis of cutaneous granulomatous disorders (CGDs) is usually suspected based on morphologic findings, localization, and anamnestic data, clinical differentiation from each other and from similar dermatoses may be challenging. Recently, dermatoscopy has been demonstrated to be a useful tool for assisting the recognition of several CGDs. This article provides a current overview of the dermatoscopic features of the main noninfectious and infectious CGDs, including sarcoidosis, necrobiosis lipoidica, granuloma annulare, rheumatoid nodules, and leishmaniasis. Other, less common, CGDs are briefly addressed, including granulomatous rosacea, acne agminata, and leprosy.

Case 238: Spontaneous Pneumothorax Secondary to Intrapulmonary Necrobiotic Rheumatoid Nodule.

History A 54-year-old white woman with a history of rheumatoid arthritis who was taking glucocorticoids and methotrexate presented to the emergency department in December with worsening shortness of breath and chest heaviness for 1 week. She reported additional symptoms of weakness, headache, and arthralgia primarily involving her bilateral hands, wrist, ankles, and feet. She denied experiencing fevers, syncope or presyncope, focal neurologic deficits, chest pain, nausea, vomiting, unintentional weight loss, or recent trauma. Additional medical history included hypertension, asthma, degenerative disk disease, and migraine, all of which were reportedly controlled with medications. This patient had a smoking history of 80 pack-years, but she had quit smoking 2 months prior to presentation. She denied abuse of alcohol or recreational drugs and reported she was up-to-date on her immunizations, including those for pneumonia and flu. Family history was pertinent for breast cancer in her mother, sister, and maternal aunt. The patient reported normal findings at screening mammography and colonoscopy. A physical examination was remarkable for slightly asymmetric breath sounds, which appeared to be diminished on the right side. This patient had multiple joint deformities, most notably in the bilateral metacarpophalangeal joints. Initial electrocardiography findings and cardiac biomarkers were negative. Her complete blood count and basic metabolic profile were unremarkable. Posteroanterior and lateral chest radiographs were obtained in the emergency department. Subsequently, computed tomography (CT) of the chest was performed.

Rheumatoid nodules and quality of life in rheumatoid arthritis females - complex assessment.

Rheumatoid arthritis (RA) represents the most commonly diagnosed arthropathy that affect many tissue types and organs, characterized by a clinical, functional and therapeutic pathogenic complexity and it affects especially diarthroidal joints. Rheumatoid nodules (RNs) are one of the most frequent extra-articular manifestations of RA, and usually reflect an advanced stage of the disease and a poor prognosis. The complexity of histological, clinical and functional aspects in RA has a real impact on the quality of life in all patients diagnosed with this disorder. Our prospective study presents the RNs involvement in the rehabilitation program performed in order to enhance the quality of life in the 25 RA female patients. We made a complex assessment and realized a correlation between pain, disability and histological aspect of RN, before and after the rehabilitation program. Also, we evaluated the clinical and functional effectiveness of a complex rehabilitation program and changes in impairment and activity limitation in women with RA and RNs. The immunohistological complexity of RNs reflects the intensity of the inflammatory-immune process and completes the assessment of RA patients with RNs. It allows for medical assistance quantification, even for patients that have a poor evolution prognosis.