A large pulmonary nodule in a rheumatoid arthritis patient treated with tofacitinib.

Pulmonary rheumatoid nodules are rare extra-articular manifestations of rheumatoid arthritis (RA). They are usually asymptomatic but may form cavities and cause clinical symptoms. These nodules are difficult to differentiate clinically and radiologically from tuberculosis, fungal infection, or lung malignancies. Histopathological studies help in the differential diagnosis of pulmonary nodules in patients with RA; however, an effective treatment for rheumatoid lung nodules has not yet been established. This study reports a case of active RA with interstitial lung disease and a large inflammatory lung nodule that was improved with tofacitinib treatment.

Methotrexate-associated lymphoproliferative disorder with multiple pulmonary nodules and bilateral cervical lymphadenopathy.

As has been well recognized, methotrexate (MTX) leads to a state of immunosuppression and can provide a basis for the development of lymphoproliferative disorders (LPDs). MTX-associated LPDs can affect nodal sites as well as extranodal sites, though the manifestation of an LPD in the form of multiple pulmonary nodules is rare. Here, we report two cases of MTX-associated LPD with multiple bilateral pulmonary nodules, which was a finding suggestive of lung cancer, and bilateral cervical lymphadenopathy. After withdrawal of MTX, the multiple bilateral pulmonary nodules and bilateral cervical lymphadenopathy disappeared without chemotherapy in both cases. From these results, patients with pulmonary nodules and cervical lymphadenopathy should be examined for head and neck malignant tumors. Also, physicians should carefully check the administration of MTX. In patients with an MTX-associated LPD, we need to make an early diagnosis and consider discontinuing the administration of MTX as soon as possible.

Transient Asymptomatic Pulmonary Opacities During Osimertinib Treatment and its Clinical Implication.

INTRODUCTION: Osimertinib is an oral, potent, irreversible third-generation EGFR tyrosine kinase inhibitor approved for the treatment of T790M-positive NSCLC patients who failed first- or second-generation EGFR tyrosine kinase inhibitors. Interstitial lung disease (ILD) is a rare complication with osimertinib, occurring in 1% to 3% of patients. Recently, a relatively high incidence of transient asymptomatic pulmonary opacities (TAPOs), which are different from ILD, has been described. However, its clinical implication has not been fully determined yet. METHODS: We retrospectively analyzed 74 EGFR T790M mutant NSCLC patients treated with osimertinib. Serial computed tomographic findings were reviewed by a thoracic radiologist independently, and TAPO was classified according to its radiologic pattern. We also analyzed the correlation of TAPO with clinical outcomes. RESULTS: Among 74 patients, TAPOs were found in 15 (20.3%). The median time to TAPO development was 24.0 weeks (range, 1 to 72 weeks) and the median duration of TAPO was 6.0 weeks (range, 5 to 24 weeks) during continued osimertinib treatment. The most common radiological patterns of TAPO include cryptogenic organizing pneumonia and/or simple eosinophilic pneumonia. There was no significant difference in patient characteristics between TAPO-positive and -negative groups. The duration of exposure to osimertinib was significantly longer in TAPO-positive than -negative groups (25.0 months versus 13.0 months, p = 0.009). The median progression-free survival and the median overall survival was numerically longer in TAPO-positive than -negative groups (22 months versus 15 months for progression-free survival, p = 0.293; 37 months versus 24 months for overall survival, p = 0.059), respectively. CONCLUSIONS: TAPOs are frequently observed with osimertinib treatment and may be mistaken for isolated pulmonary progression or drug-induced ILD. Given the lack of serious clinical deterioration, it is reasonable to continue osimertinib with regular computed tomographic-scan follow-up. For further clinical validation of TAPOs, long-term follow-up and large studies are warranted.

Seasonal Influenza Vaccine-induced Pneumonitis Presenting with Multiple Pulmonary Nodules.

A 39-year-old woman received a seasonal influenza vaccine in November 2015 and subsequently experienced malaise, low-grade fever, and chest discomfort. A chest X-ray performed 2 weeks after vaccination showed multiple nodular shadows in both lungs and ground-glass shadows in both lower lung fields. Her bronchoalveolar lavage fluid contained an unusually high number of lymphocytes, and a drug-induced lymphocyte stimulation test for seasonal influenza vaccine was positive. Transbronchial lung biopsy revealed the presence of granulomatous inflammation. Thereafter her abnormal chest shadow spontaneously improved. Based on these findings, the patient was diagnosed with drug-induced pneumonitis due to an influenza vaccine.

Polishing surgical metal pieces, granulomatosis and mineralogical analysis.

This report describes the case of a 44-year-old man with pulmonary nodules whose histological analysis initially suggested tuberculosis. The Mycobacterium tuberculosis (MT) culture was negative and a questionnaire revealed a professional activity of brushing and polishing surgical instruments without any protection for 7 years.  A mineralogical analysis by optical and electron microscopy was performed on both a healthy lung tissue biopsy and a lung nodule in a paraffin block. Electron microscopy analysis revealed the presence of metal particles (iron oxide, titanium oxide, aluminum oxide and steel) in both samples. This study suggests that mineralogical analysis combined with a questionnaire on dust exposure could help redirect the diagnosis of a dust-related disease.

Azathioprine-induced accelerated cutaneous and pulmonary nodulosis in a patient with rheumatoid arthritis.

We report the case of a 42-year-old female with a 5-year history of rheumatoid arthritis treated with Rituximab and Azathioprine. Three months after the initiation of Azathioprine, the patient started with dry cough and noted the rapid development of multiple subcutaneous nodules on her right leg. CT scan of the chest demonstrates pulmonary nodulosis. Skin biopsy was compatible with rheumatoid nodule. A diagnosis of "accelerated cutaneous and pulmonary nodulosis" was considered. Azathioprine was discontinued and Rituximab was restarted. Two months later, most of the subcutaneous nodules had disappeared. This is the second case report of accelerated rheumatoid nodulosis in association with Azathioprine treatment.

Formation of multiple pulmonary nodules during treatment with leflunomide.

Pulmonary involvement is one of the extra-articular manifestations of rheumatoid arthritis and can be due to the disease itself or secondary to the medications used in order to treat it. We report the case of a 60-year-old woman who had been diagnosed with rheumatoid arthritis and developed multiple pulmonary nodules during treatment with leflunomide.

Methotrexate-associated Lymphoproliferative Disease with Multiple Pulmonary Nodules in a Patient with Rheumatoid Arthritis.

Patients with rheumatoid arthritis (RA) treated with methotrexate (MTX) sometimes develop lymphoproliferative disease (LPD). MTX-associated LPD can affect nodal or extranodal sites, including the gastrointestinal tract, skin, lungs, kidneys and soft tissues, at almost equal frequency. However, it is very rare for MTX-associated LPD to manifest as multiple nodules in the lungs. We herein report the case of a RA patient who developed MTX-associated LPD with multiple pulmonary nodules during a 5-year course of MTX therapy.

Formation of multiple pulmonary nodules during treatment with leflunomide / Formação de múltiplos nódulos pulmonares durante tratamento com leflunomida

Pulmonary involvement is one of the extra-articular manifestations of rheumatoid arthritis and can be due to the disease itself or secondary to the medications used in order to treat it. We report the case of a 60-year-old woman who had been diagnosed with rheumatoid arthritis and developed multiple pulmonary nodules during treatment with leflunomide.

O comprometimento pulmonar é uma das manifestações extra-articulares da artrite reumatóide e pode ser devido à própria doença ou secundário às medicações utilizadas para seu tratamento. Este trabalho relata um caso de uma paciente de 60 anos de idade com diagnóstico de artrite reumatoide que evoluiu com múltiplos nódulos pulmonares durante o tratamento com leflunomida.

Azathioprine-induced accelerated cutaneous and pulmonary nodulosis in a patient with rheumatoid arthritis

We report the case of a 42-year-old female with a 5-year history of rheumatoid arthritis treated with Rituximab and Azathioprine. Three months after the initiation of Azathioprine, the patient started with dry cough and noted the rapid development of multiple subcutaneous nodules on her right leg. CT scan of the chest demonstrates pulmonary nodulosis. Skin biopsy was compatible with rheumatoid nodule. A diagnosis of "accelerated cutaneous and pulmonary nodulosis" was considered. Azathioprine was discontinued and Rituximab was restarted. Two months later, most of the subcutaneous nodules had disappeared. This is the second case report of accelerated rheumatoid nodulosis in association with Azathioprine treatment.

Resolution without treatment of granulomatous pneumonitis due to intravesical BCG for bladder cancer.

Granulomatous pneumonitis is a well-recognised complication of intravesical BCG therapy. The mechanism is sometimes thought to be 'hypersensitivity' rather than infection as in most cases mycobacteria are not cultured. Despite this it is usually treated with antituberculous chemotherapy with or without corticosteroid. We describe a case of bladder cancer treated with intravesical BCG followed by a febrile illness and malaise lasting for months and the development of miliary pulmonary shadowing, which markedly improved in around 1 year without any treatment. The clinical syndrome was less severe than some others described but this case provides evidence that, at least in some cases, no specific treatment may be necessary.

[Pulmonary nodules and arachnophobia]. / Nodules pulmonaires et arachnophobie.

Pulmonary nodules are a common reason for consultation and their investigation must always exclude a possible neoplastic cause. This means that, in addition to a thorough history, investigations may be necessary which are sometimes invasive and therefore potentially a cause of iatrogenic harm. The toxic aetiologies for pulmonary nodules are rare. We report a case of a patient with pulmonary nodules occurring predominantly in the right lung, about 1cm in diameter, non-cavitating without calcification, and sometimes surrounded by a peripheral halo. The nodules were a chance finding during preoperative evaluation. After a comprehensive review, a reaction to an inhaled irritant was the preferred hypothesis, specifically overuse of a compound insecticide containing, in addition to the propellant gas and solvent type hydrocarbon - a mixture of piperonyl butoxide, of esbiothrine and permethrin. Removal of this led to the complete disappearance of nodules. Pathological examination identified bronchiolitis obliterans with organising pneumonia accompanied by non-necrotizing granulomas and lipid vacuoles.

Recurrent pneumothorax associated with pulmonary nodules after leflunomide therapy in rheumatoid arthritis: a case report and review of the literature.

Rheumatoid arthritis (RA) is a multisystem inflammatory disease characterized by destructive synovitis and systemic extraarticular involvement. One of the most common pulmonary manifestations of RA is rheumatoid nodule. Spontaneous pneumothorax also very rare pulmonary finding and could be associated with pulmonary nodules. Antirheumatic drugs, methotrexate, leflunomide (LEF), infliximab and etanercept, were known as risk factors for developing rheumatoid nodule. However, there was no case report of rheumatoid nodule-associated pneumothorax with the use of LEF. We report, first, herein a case of 46-year-old woman with RA who suffered recurrent spontaneous pneumothorax associated with multiple bilateral subpleural cavitary nodules during treatment with LEF. We reviewed the cases of LEF-related pulmonary nodules developed in patients with RA. Thus, we suggested that pneumothorax can be a rare respiratory fatal complication in patients with RA with pulmonary nodules and LEF can be a rare cause of these manifestations.