Thoracic Manifestations of Rheumatoid Arthritis

Abstract

Rheumatoid arthritis (RA) is commonly associated with pulmonary disease that can affect any anatomic compartment of the thorax. The most common intrathoracic manifestations of RA include interstitial lung disease, airway disease, pleural disease, rheumatoid nodules, and drug-induced toxicity. Patients with RA with thoracic involvement often present with nonspecific respiratory symptoms, although many are asymptomatic. Therefore, clinicians should routinely consider pulmonary disease when evaluating any patient with RA, particularly one with known risk factors. The optimal screening, diagnostic, and treatment strategies for RA-associated pulmonary disease remain uncertain and are the focus of ongoing investigation.

Keywords: Bronchiectasis; Bronchiolitis; Drug-induced lung toxicity; Rheumatoid arthritis; Rheumatoid arthritis–associated interstitial lung disease; Rheumatoid nodule.

Fig. 1.

Rheumatoid arthritis-associated interstitial lung disease subtypes. (A) Usual interstitial pneumonia with characteristic basilar-predominant honeycombing (solid arrow) and subpleural reticulation with traction bronchiectasis. (B) Non-specific interstitial pneumonia discernible by relatively symmetric subpleural ground glass opacities with immediate subpleural sparing (arrowheads). (C) Cryptogenic organizing pneumonia with bilateral mid-to-lower lung predominate consolidative opacities in a peripheral and peribronchovascular distribution (dashed arrows). (D) Lymphocytic interstitial pneumonia marked by scattered thin-walled cysts (double arrow) and ground-glass opacification.

Fig. 2.

Suggested algorithm to identify interstitial lung disease in patients with rheumatoid arthritis. Abbreviations: CCP cyclic citrullinated peptide; CT computed tomography; DLCO diffusion capacity of the lung for carbon monoxide; HRCT high resolution computed tomography; ILD interstitial lung disease; PFTs pulmonary function tests; RA rheumatoid arthritis; RF rheumatoid factor.

Fig. 3.

Rheumatoid arthritis-associated small airway disease. Inspiratory (A) and expiratory (B) high-resolution computed tomography images of a patient with bronchiolitis. Solid arrows: bronchiectasis. Arrowheads: mosaic attenuation characteristic of air trapping and small airway disease is accentuated on expiratory images.

Fig. 4.

Rheumatoid arthritis-associated pleural disease. (A) Bilateral pleural thickening and hyperenhancement (solid arrows) with associated loculated pleural effusions, indicating pleuritis. (B) Necrobiotic cavitary nodule (arrowhead) resulting in a spontaneous pneumothorax (dashed arrow).