Rheumatoid arthritis (pulmonary manifestations)

Pulmonary manifestations are relatively common in rheumatoid arthritis, and like many of its non-articular manifestations, tend to develop later in the disease.

Please refer to the related articles for a general discussion of rheumatoid arthritis, and for the specific discussion of its musculoskeletal manifestations.

Epidemiology

Although rheumatoid arthritis is more common in women, respiratory disease more commonly develops in men ⁶.

Clinical presentation

Respiratory symptoms are often absent, or non-specific such as dyspnea and chronic cough. 

Pathology

Associations

• bronchocentric granulomatosis: rare ⁷

Radiographic features

Patterns of lung involvement include interstitial, airway and pleural disease.

Pleural involvement is a common manifestation of rheumatoid arthritis, although usually asymptomatic. 

• pleural thickening: is seen more commonly than pleural effusions
• pleural effusions: occur late in the disease, are often unilateral and associated with pericarditis and subcutaneous nodules ⁵

Other manifestations include:

• pulmonary fibrosis
• peribronchiolar metaplasia 
• rheumatoid lung nodules

Plain radiograph

Chest radiograph may show: 

• pleural effusion
• lower zone predominant reticular or reticulonodular pattern
• volume loss in advanced disease
• skeletal changes, e.g. erosion of clavicles, glenohumeral erosive arthropathy, superior rib notching

CT

Chest CT or HRCT features include:

• pleural thickening or effusion
• ground-glass densities ⁸
• interstitial fibrosis (rheumatoid arthritis associated interstitial lung disease)
  • reticulation
  • occurs in ~10% of RA patients ³
  • can have either a UIP (slightly more common ⁸) or NSIP pattern
• organizing pneumonia
• bronchiectasis
• bronchiolitis obliterans
• large rheumatoid nodules
  • single or multiple
  • tend to be based peripherally
  • may cavitate (necrobiotic lung nodules)
  • cavitation of a peripheral nodule can lead to pneumothorax or hemopneumothorax
• follicular bronchiolitis: rare
  • small centrilobular nodules or tree-in-bud
• Caplan syndrome

 See also

• rheumatoid arthritis (general article)
  • musculoskeletal manifestations of rheumatoid arthritis
• rheumatoid pulmonary vasculitis