An open lung biopsy case of follicular bronchiolitis in rheumatoid arthritis

A 49 year-old Japanese female with a clinical history of rheumatoid arthritis for 15 years developed fever, cough, sputa and exertional dyspnea. A chest x-ray showed right-sided pleural lesions in addition to persistent hyperinflation of the lungs for about four years. Pulmonary function tests showed combined obstructive and restrictive dysfunction, increased residual volume and reduced diffusing capacity. After an improvement of the pleural lesions, she underwent a right open lung biopsy in December 1988 which revealed follicular bronchiolitis and fibrino-fibrous pleural thickening. The pulmonary lesion of follicular bronchitis/bronchiolitis was reported in 1985 as a newly recognized pulmonary disorder among open lung biopsy cases. The present case was the second biopsy proven case of follicular bronchiolitis among the Japanese.     

Follicular bronchiolitis preceding rheumatoid arthritis]

A 52-year-old woman visited our hospital because of a cough and stridor in 1994. She had a history of non-tuberculous mycobacteriosis and chronic paranasal sinusitis. Her chest CT scan showed scattered centrilobular nodular shadows and peribronchial thickening, and so we suspected recurrent non-tuberculous mycobacteriosis or diffuse panbronchiolitis. Clarithromycin treatment was initiated, but she soon ceased taking the drug. She visited our hospital again because of a severe cough three and half years later. A new chest CT scan showed increased abnormal shadows, and so we suspected worsening non-tuberculous mycobacteriosis or diffuse panbronchiolitis. Consequently, we commenced treatment with rifampicin, ethambutol hydrochloride as well as clarithromycin. One year later, rheumatoid arthritis was diagnosed because of a swollen proximal interphalangeal joint in both fourth fingers. Her respiratory symptoms were not relieved with clarithromycin or antituberculous drugs, so a thoracoscopic biopsy was performed for a more accurate diagnosis. Histological examination revealed follicular bronchiolitis.     

A case of bronchiolitis obliterans organizing pneumonia in a patient with rheumatoid arthritis

A 54-year-old man with rheumatoid arthritis visited his general practitioner because of fever and cough. Chest X-ray showed an infiltrative shadow in the right lower field. Antibiotic treatment was not effective, and the specimens obtained by transbronchial lung biopsy was not diagnostic. The patient was transferred to our hospital for further examination and treatment. Previously he had been treated with prednisolone in the knee joint for rheumatoid arthritis. Open lung biopsy was performed. The specimen obtained showed bronchiolitis obliterans organizing pneumonia (BOOP) histologically. The patient recuperated and the chest X-ray shadow decreased with no therapy except the previous treatment with prednisolone.     

Obliterative bronchiolitis in rheumatoid arthritis

Two patients with rheumatoid arthritis who developed obliterative bronchiolitis are described. Both patients had received penicillamine. The first patient died in respiratory failure 4 months after the onset of her breathlessness and the diagnosis was confirmed at post-mortem. The second patient was diagnosed with appropriate lung function tests and has been started on azathioprine. Although she is still disabled by breathlessness 12 months after presentation, her condition has stabilised.     

Minocycline for the treatment of bronchiolitis obliterans associated with rheumatoid arthritis]

We discribe a rare case of rheumatoid arthritis (RA) complicated with bronchiolitis obliterans that was successfully treated with minocycline. Sixty four-year old woman with a four-years history of RA was admitted to the hospital because of dyspnea on exertion and polyarthritis. Pulmonary function test revealed marked decrease in V25 (0.10 l/s: 6.9%) and MMFR (12.6%). High resolution CT of the lung showed scattered centri-lobular micronodules in both lung fields, mucoid impaction, and hyperinflation. These findings indicated the presence of bronchiolitis obliterans. After 3 months of the treatment with minocycline, the patient showed a significant improvement of both arthritis and pulmonary function. Chest CT findings also improved after 1 year. The present case suggests that minocycline is effective for the treatment of bronchiolitis obliterans seen in patients with RA.     

Follicular bronchiolitis associated with rheumatoid arthritis.

Follicular bronchiolitis is a rare disorder, though it has been recognized as a pulmonary involvement of rheumatoid arthritis in recent years. A 57-year-old woman with rheumatoid arthritis was admitted to the hospital with persistent productive cough and breathlessness on exertion. An open lung biopsy was performed to establish a definite pathologic diagnosis of her disease, and she was diagnosed as having follicular bronchiolitis on the basis of the histopathological findings. It is essential to differentiate this disease from other bronchiolar or lymphoproliferative disorders of the lung.     

A case of bronchiolitis obliterans organizing pneumonia in a patient with rheumatoid arthritis who responded to corticosteroid and immunosupressant therapy]

A 56-year-old man with rheumatoid arthritis was admitted to our hospital with dyspnea on exertion, fever and right chest pain. Chest X-ray showed bilateral, predominantly lower interstitial shadows and right pleural effusion. Open lung biopsy specimen showed bronchiolitis obliterans organizing pneumonia (BOOP) with prominent alveolitis, and corticosteroid therapy was introduced. Because the patient showed little response to corticosteroids, an immunosupressant (cyclophosphamide) was added. There was marked clinical, physiological and roentgenographic improvement in response to combined therapy. The therapeutic response of some BOOP patients seems to vary according to its pathogenesis and pathological findings, and these should be taken into consideration in the selection of therapeutic strategies.     

A case of rheumatoid arthritis with secondary amyloidosis in urinary bladder]

We document a case of 61-year-old woman with a 24 year history of rheumatoid arthritis (RA), who developed severe polyarthralgia, dry cough, paresthesia in the legs, frequent micturition, and severe macrohematuria. We diagnosed as severe RA with extraarticular manifestations based on interstitial pneumonia, mononeuritis multiplex, subcutaneous nodules, and high titer of rheumatoid factor. Ultrasonography demonstrated an intravesical mass lesion. A histological examination of the urinary bladder by endoscopic biopsy revealed marked deposition of AA amyloid. The diagnosis of secondary amyloidosis and bacterial cystitis were made based on histological findings and urine culture. At first, we administered antibiotics by intravenous infusion, which resulted in cure of cystitis and partial improvement of macrohematuria. Then combination therapy of corticosteroids and cyclophosphamide successfully reduced the disease activity of RA. There have only been a few reports published so far on the vesical amyloidosis in patients with RA. However, 5 of 10 patients (50%) in vesical amyloidosis died because of continuous massive hematuria, which induced disseminated intravascular coagulation and multiple organ failure. In conclusion, secondary amyloidosis of the urinary bladder should be considered as a possible cause of hematuria in patients with long-term RA and as an important prognosis factor of RA.     

A case report of rheumatoid arthritis patient with thoracic myelopathy]

The authors report a 39-year-old woman with rheumatoid arthritis associated with myelopathy at the thoracic level. X-ray films of thoracic spine showed scoliosis which had its apex at T6. Myelography demonstrated incomplete block at the level of T6. Computerized tomogram revealed destruction of left pedicle of the sixth thoracic vertebra and dislocation of the sixth rib into the spinal canal which compressed cord at T6 level. Hemi-laminectomy at T5-T7 level and decompression were performed. Pathological investigations of soft tissue around the cord and dura mater showed infiltration of small round cells. We concluded that the synovitis of costo-transverse joint or costovertebral joint led to the destruction of the pedicle. As a result, dislocation of the rib, scoliotic deformity and thoracic myelopathy occurred.     

Cellular interstitial pneumonia and follicular bronchiolitis diagnosed by open lung biopsy in a patient with rheumatoid arthritis

A 54-year-old woman under treatment for rheumatoid arthritis was admitted because of aggravation of dyspnea on effort and restrictive pulmonary dysfunction. Although chest X-ray revealed no marked change, the symptoms progressively worsened, necessitating open lung biopsy for diagnosis and treatment. Based on the histopathological findings of the biopsied tissue, the patient was diagnosed as having active rheumatoid lung complicated with cellular interstitial pneumonia and follicular bronchiolitis. The patient responded well to adrenocorticosteroid and immunosuppressor therapy, and is now being followed up as an outpatient. Rheumatoid arthritis can be complicated by diverse lung diseases. Among them one important disease is interstitial pneumonia, which serves as a prognostic factor. When cellular interstitial pneumonia is treated with adrenocorticosteroid therapy, it responds well and its prognosis is good. Therefore, its early detection and appropriate adrenocortical therapy are essential. Patients with rheumatoid arthritis presenting with dyspnea on effort and pulmonary dysfunction should be examined for cellular interstitial pneumonia, follicular bronchiolitis and other lung diseases, even when no marked change is visible on chest X-ray films.     

Post-pneumonectomy pyothorax with and without broncho-pleural fistula

This study reports the experience of the medical centre of Villiers Saint-Denis, where about 40 cases of pyothorax with or without broncho-pleural fistula were seen between 1975 and 1981. The authors describe their method to drain and wash the pleural cavity. They use a single chest tube with an irrigation system in simple empyema and two chest tubes with an irrigation system when they must close a broncho-pleural fistula. With this method, the infection was eradicated in 90% of the cases, and the broncho-pleural fistula closed within about 4 months in 80% of the cases. This method is compared with other methods used to treat pyothorax.     

A case of drug-induced interstitial pneumonitis in rheumatoid arthritis treated with bucillamine]

We report a case of bucillamine-induced interstitial pneumonitis in a 57-year-old woman. Rheumatoid arthritis was diagnosed in May 1999, and she was treated with bucillamine from June 1999, with a favorable outcome. After complaining of cough, fever, and dyspnea in October, she was admitted to this hospital. Blood gas analysis showed severe hypoxemia. The chest CT revealed both bilateral diffuse ground-glass opacity along the bronchovascular bundles, and thickening of the interlobular septa. We suspected bucillamine-induced interstitial pneumonitis from the findings of the CT scan, BALF and TBLB, and also from the improvement of PaO2 after the withdrawal of bucillamine. We treated the patient with prednisolone, and a favorable response was noted. A lymphocyte stimulation test using bucillamine was positive. A video-assisted thoracic surgery lung biopsy showed findings compatible with acute interstitial pneumonia without the association of hyaline membrane formation. A focal fibrosis was also observed. We believe that this is the only reported case of pathologically proven bucillamine-induced interstitial pneumonitis, in which a surgical lung biopsy was performed.     

Aorto-atrial fistula in rheumatoid arthritis

A patient with severe deforming rheumatoid arthritis presented with a short history of chest pain. The clinical signs were of an unusual diastolic murmur and profound shock unresponsive to therapy. Post-mortem examination disclosed the unexpected finding of a large aorto-atrial fistula.     

A case of rheumatoid arthritis complicated with auranofin-induced acute interstitial pneumonitis]

A case of auranofin(AF)-induced acute interstitial pneumonitis in a patient with rheumatoid arthritis (RA) is reported and possible mechanism of the incidence is discussed. A 57 year-old woman with a history of RA starting in early April 1989, had been prescribed AF for seven days prior to her referral to this hospital. Because of the severity of her polyarthritis, AF was discontinued; therapy with gold sodium thiomalate (GST) instead was started on 23 June 1989. The patient responded quite favorably. At a total cumulative dose of 160mg of GST, however, she developed generalized exfoliative dermatitis and the drug was discontinued. On 29 Sept. 1989 when her skin lesions cleared up completely, she was put on AF again. Six days after resumption of AF therapy, she developed fever. Nonproductive cough and dyspnea on exertion was observed within the following three days. The chest X-ray film revealed diffuse reticular-linear infiltrates more prominently in both upper lobes. Arterial blood gas studies showed hypoxemia and a restrictive ventilatory defect was demonstrated by pulmonary function studies. AF was stopped. High dose pulse iv corticosteroid(CS) therapy combined with oral CS was instituted. Immediate improvement of both subjective and objective findings was observed. By using the patient's peripheral blood lymphocytes, delayed lymphocyte stimulation test(DLST) against the probable causative agents was performed before the bolus CS therapy. Stimulation Index(shown in percentage) was markedly elevated in AF(724%) as compared with GST(163%). The fiberoptic bronchoscopy with bronchoalveolar lavage(BAL) was performed. Analysis of BAL fluid revealed increased cellularity (9 x 10(5)/ml) with marked lymphocytosis of 79%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Esophago-bronchial fistula in a patient with rheumatoid arthritis

A 58-year-old woman with active rheumatoid arthritis developed an esophago-bronchial fistula in close temporal proximity to the eruption of subcutaneous nodules and a worsening of her joint symptoms. Possible mechanisms to explain the fistula formation are discussed.