Cavitary pulmonary rheumatoid nodules in a patient on leflunomide: A case report

Abstract

Rheumatoid arthritis is a chronic inflammatory rheumatic disease that can cause extra-articular manifestations, in particular pleuropulmonary involvement, which is the second leading cause of death in this connective tissue disease. We report a rare pulmonary manifestation of RA. This was a 58-year-old patient being followed for RA on leflunomide with 3 excavated pulmonary nodules measuring 13 mm, 10 mm and 6 mm, for which the diagnostic hypotheses of infection, pulmonary metastases and rheumatoid nodules had been put forward. The diagnosis of excavated pulmonary nodules in rheumatoid arthritis was made after aspiration of one of the nodules, which ruled out infectious and cancerous causes. These nodules regressed 6 months after leflunomide was stopped.

Keywords: Leflunomide; Pulmonary nodules; Rheumatoid arthritis.

Fig. 1

Chest CT scan with parenchymal window showing 3 excavated pulmonary nodules. Image (A), shows 2 nodules excavated from the lower lobe of the right lung, 1 measuring 10 mm, subpleural in topography, and the other measuring 6 mm, intraparenchymal. In image (B), a 13 mm nodule is seen excavated intra-parenchymal with subpleural extension.

Fig. 2

Scan-guided aspiration of a 10 mm nodule of subpleural topography in the lower lobe of the right lung.

Fig. 3

Chest PET scan showing the hypermetabolic nature of the 3 excavated pulmonary nodules.

Fig. 4

Chest CT scan with parenchymal window performed 6 months after stopping leflunomide, showing regression of the 3 excavated pulmonary nodules. Image (A) shows the disappearance of the 2 nodules excavated in the lower lobe of the right lung compared with Figure 1A. In image (B), the parenchymal nodule with sub-plural extension of the left lobe has also completely regressed compared with Figure 1B.