Multiple pulmonary cavitary nodules with pyoderma gangrenosum in patient with rheumatoid arthritis

Abstract

Pyoderma gangrenosum (PG) is a rare ulcerative neutrophilic disorder of skin. Its pulmonary manifestations are uncommon and only less than forty cases have been reported in the literature previously. PG is associated with variable systemic diseases, most commonly inflammatory bowel disease and hematologic malignancies. It reported rarely in rheumatoid arthritis (RA). We report a case of PG lung involvement in patient with RA associated interstitial lung disease. A 66-year-old woman presented with productive cough and recurrent ulcerative lesion on her left ankle. She had a 15-year history of RA associated interstitial lung disease and treated with methotrexate, sulfasalazine, hydroxychloroquine and methylprednisolone. On physical examination, there were a few tender, erythematous subcutaneous nodules ranging from 1 to 3 cm in diameter on her left thigh and left elbow. Anti-neutrophil cytoplasmic antibodies (ANCAs) are negative. Her chest CT scan demonstrated multifocal cavitary consolidations on the background of reticular opacity and honeycombing. Punch biopsy of erythematous nodule on thigh showed neutrophilic abscess with necrotic debris. The skin and lung lesions were rapidly improved with 0.5 mg/kg/day of prednisolone.

Keywords: Multiple cavitary lung nodules; pyoderma gangrenosum (PG); rheumatoid arthritis (RA).

Figure 1

Ulcerative lesion on anterior side of left ankle in 2011. The lesion had necrotic and hemorrhagic base and elevated erythematous border.

Figure 2

Chest X-ray and Chest CT scan. (A) Chest X-ray showed cavitary consolidation in right hilar area and reticular opacities in bilateral basal lungs; (B) chest CT scan showed multiple cavitary consolidations in right middle lobe and right lower lobe and subpleural honeycombing in both lower lobes

Figure 3

Histologic finding of erythematous nodule on thigh. There were many neutrophils and fibrinoid necrosis (H&E, ×100).

Figure 4

Follow up chest X-ray, chest CT and photograph of left ankle. (A) Chest X-ray showed improving state of cavitary lesion after steroid treatment; (B) chest CT scan also showed improving state of multiple cavitary lesions; (C) pyoderma gangrenosum on lateral side of left ankle improved after treatment, too.