Progressive intraparenchymal lung nodules dissemination in a heavy smoker and seropositive rheumatoid arthritis suspected of tuberculosis relapse.

Anthony Caplan first described rheumatoid lung nodules associated with pneumoconiosis in coal-miners (Caplan, 1953). Intraparenchymal lung nodules were later described in rheumatoid arthritis (RA) patients who were never exposed to coal dust and/or without pneumoconiosis. Rheumatoid lung nodules are usually detected in unselected patients: 0.2% in chest radiography and 4% in high-resolution computed tomography (Nannini et al., 2008). Patients could be reluctant to perform surgical lung biopsy for an accurate histopathological diagnosis. We present a peculiar association between a seropositive RA and a presumptive active tuberculosis (TB) disease in a 59-year-old male patient, ex-smoker with a previously healed pulmonary TB disease. The purpose of this report is to describe an unusual case of a presumptive relapse of the nodular TB disease, which progressed to an extensive nodular bilateral dissemination under anti-tuberculosis therapy, mimicking a metastatic carcinoma. The diagnosis of rheumatoid necrobiotic lung nodules was confirmed after open biopsy left pulmonary was performed. Formalin-fixed paraffin-embedded pulmonary rheumatoid nodules were processed for histology and stained with Masson's trichrome. Central structure of the removed pulmonary nodules is typical of a rheumatoid nodule with central necrosis surrounded by a palisade of macrophages. The accumulation of anthracotic pigment was noticed inside the pulmonary nodules in a RA patient without professional exposure to coal or mineral dust. This rare entity is an appearance of the rheumatoid nodules lung syndrome and anthracosis in a heavy tobacco former smoker.

Aspergillus colonisation of pulmonary rheumatoid nodules: a rare cause of 'bull's eye' appearance.

Pulmonary rheumatoid nodules [PRNs] are a well described manifestation of rheumatoid arthritis [RA]. Fungal colonisation of these nodules is a rare phenomenon. We report a case of Aspergillus colonisation of multiple cavitary rheumatoid nodules in a young female patient with long-standing seropositive RA with 'bull's eye' appearance on computed tomography [CT]. The 'bull's eye' appearance inside PRNs should raise the suspicion of possible fungal colonisation. In patients with RA, a high index of suspicion for the fungal colonisation should be considered by the clinicians treating pulmonary cavitary nodules.

Bilateral spontaneous pneumothorax in a patient with pulmonary rheumatoid nodules, secondary infected by Aspergillus.

This case report describes a 50-year-old woman with rheumatoid arthritis (RA) in whom nodular opacities were found on chest X-ray. She developed a bilateral spontaneous pneumothorax treated with surgical pleurodesis. Cultures remained negative. Histological examination of specimens confirmed the clinical diagnosis of rheumatoid granulomata. Therefore, corticosteroid therapy was started, after which the nodules decreased slightly in size and inflammatory parameters normalized. Three months later, she presented with respiratory insufficiency based on pulmonary fungus infection. Differential diagnosis between rheumatoid nodules and granulomas caused by Aspergillus is difficult in RA patients with pulmonary nodular lesions; in this case, both complications appeared subsequently.

Fungus colonisation of pulmonary rheumatoid nodule.

This report describes a 69 year old woman, suffering from active rheumatoid arthritis since the age of 60 and presenting with severe dyspnoea and cough. A computed tomography scan of the chest showed multiple bilateral pulmonary nodules, sometimes cavitated, associated with reticular opacities and pleural effusion. A videothoracoscopic excision of a cavitated nodule was performed. Seven days after surgery, a right pneumothorax developed, and the patient died of septicaemia one month later. Microscopically, the excised nodule was composed of necrotic fibrinoid material with a peripheral rim of palisaded histiocytes, extending to the pleural surface and containing several fungal hyphae morphologically consistent with aspergillus. A diagnosis of pulmonary rheumatoid nodule with fungus colonisation was made. In the lung, fungus colonisation is a rare complication of rheumatoid nodules. The most important differential diagnostic considerations are briefly discussed.

Tenosynovial nodulosis in a patient infected with human T cell lymphotropic virus I.

We describe a 45-year-old man who presented with multiple nodules along the tendons of the scapular region, the elbows, wrists, forearms, thighs, and ankles. The patient was a carrier of human T cell lymphotropic virus I (HTLV-I), which was probably transmitted from his mother; his mother also had polyarthritis. Histopathologically, the nodules consisted of numerous, small, fibrinoid masses. The synovium adjacent to the tendon sheath was hyperplastic, with fibrinoid necrosis mimicking rheumatoid synovium. However, synovitis was not present inside the adjacent joint. HTLV-I proviral DNA was detected in the cells of the nodule, in tenosynovial cells, and in peripheral blood lymphocytes, but not in skin fibroblasts. In situ reverse transcription assay showed a high quantity of tax/rex messenger RNA in the proliferating lining cells. Based on these features, we classified this case as an atypical manifestation of HTLV-I-associated arthropathy associated with fibrinoid nodules resulting from chronic tenosynovitis.

Absence of Epstein-Barr virus carrying cells in synovial membranes and subcutaneous nodules of patients with rheumatoid arthritis.

OBJECTIVES: To determine whether the Epstein-Barr virus is present in synovial membranes and subcutaneous nodules of patients with rheumatoid arthritis. METHODS: A sensitive in situ hybridisation technique was applied to tissue sections of 11 synovial membranes and five rheumatoid nodules. RESULTS: Cells carrying the Epstein-Barr virus were not detected using EBER and BHLF1 oligonucleotides in the tissue samples investigated here. CONCLUSIONS: Although it has been suggested that the Epstein-Barr virus could play a part in the aetiology of rheumatoid arthritis, it was not detected in synovial membranes and subcutaneous lesions in this study.