Therapeutic management of patients with rheumatoid arthritis and associated interstitial lung disease: case report and literature review

Abstract

Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that can present different extrarticular manifestations involving heart, lungs and kidneys. In recent years there has been a growing awareness of the central role played by the lungs in the onset and progression of RA. In particular interstitial lung disease (ILD) is a common pulmonary manifestation that may be related to the inflammatory process itself, infectious complications and to the treatments used. Management of patients with ILD/RA is still a challenge for clinicians, both synthetic [mainly methotrexate (MTX), leflunomide] and biologic immunosuppressors [mainly anti-tumor necrosis factor (TNF)α] have in fact been related to the onset or worsening of lung diseases with conflicting data. Here we report the case of a 61-year-old male patient with severely active early RA, previously treated with MTX, who developed subacute ILD, along with a review of ILD/RA topic. Tocilizumab (humanized monoclonal antibody against the interleukin-6 receptor) was introduced on the basis of its effectiveness in RA without concomitant MTX and the ability to overcome the profibrotic effects of interleukin (IL)-6. After 3 months of treatment the clinical condition of the patient strongly improved until it reached low disease activity. He no longer complained of cough and dyspnea and bilateral basal crackles were no more present. Considering its distinctive features, tocilizumab, in such a challenging clinical condition, appears to be a safe and effective therapy, thus it enables RA remission without deteriorating ILD, at 1-year follow up, as confirmed by ultrasonography of the affected joints and chest high-resolution computed tomography (HRCT).

Keywords: anti-TNFα agents; interstitial lung disease; rheumatoid arthritis; tocilizumab.

Figure 1.

Ultrasonography of the right radiocarpal joint, longitudinal scanning. (a, b) Baseline: moderate synovial hypertrophy with severe activity (power Doppler III). (c) Three months follow up: mild synovial hypertrophy with mild activity (power Doppler I).

Figure 2.

Chest high resolution computed tomography representative lung layers. (a) Baseline: inflammatory interstitial thickening with ground glass pattern (red arrows). (b) One-year follow up: reduction in size and density of the ground glass pattern.