Rheumatoid Arthritis-Associated Interstitial Lung Disease

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Rheumatoid Arthritis-Associated Interstitial Lung Disease Eunice J. Kim, MD, Harold R. Collard, MD, FCCP, Talmadge E. King, MD, FCCP CHEST Volume 136, Issue 5, Pages 1397-1405 (November 2009) DOI: 10.1378/chest.09-0444 Copyright © 2009 The American College of Chest Physicians Terms and Conditions

Figure 1 Radiographic and histopathologic appearances of NSIP and UIP. A: NSIP pattern; HRCT scan demonstrating the characteristic radiographic appearance of NSIP with bilateral, ground-glass opacities. B: NSIP pattern; lung biopsy specimen demonstrating a homogeneous cellular infiltrate typical of NSIP pattern. C: UIP pattern; HRCT scan demonstrating the characteristic radiographic appearance of a UIP pattern with bibasilar, reticular abnormalities, traction bronchiectasis, and honeycombing. D: UIP pattern; a lung biopsy specimen demonstrating areas of established fibrosis next to normal lung and focal fibroblastic activity (fibroblast foci) typical of UIP pattern (arrows). Although honeycombing is not seen on this view, the image demonstrates the classic “temporal heterogeneity” of UIP pattern. CHEST 2009 136, 1397-1405DOI: (10.1378/chest.09-0444) Copyright © 2009 The American College of Chest Physicians Terms and Conditions

Figure 2 Proportions of histopathologic UIP and NSIP in patients with CTD-ILD. Combined data from published case series of patients with various forms of CTD-ILD demonstrate that UIP pattern is more common in patients with RA-ILD. The following are data compiled and aggregated from multiple studies: scleroderma10,46,47; myositis23,48–50; Sjögren syndrome24,49,51; undifferentiated CTD5; and RA.26,27,31,49,52. CHEST 2009 136, 1397-1405DOI: (10.1378/chest.09-0444) Copyright © 2009 The American College of Chest Physicians Terms and Conditions

Figure 3 Survival data from a cohort of 28 patients with RA-ILD were compared with data from other patients with CTD-ILD and IPF. Patients with RA-ILD and UIP pattern (RA-UIP) had a worse survival time than patients with CTD-ILD and NSIP pattern (CVD-NSIP; p = 0.04), and were no different from patients with IPF. CVD = collagen vascular disease. Redrawn from Park et al40 with permission. CHEST 2009 136, 1397-1405DOI: (10.1378/chest.09-0444) Copyright © 2009 The American College of Chest Physicians Terms and Conditions

Figure 4 Proposed algorithm for the evaluation and management of suspected patients with RA-ILD. Patients with suspected RA-ILD should be screened annually for the presence of ILD with a history and a physical examination. In suspected cases of ILD, additional testing with PFTs and HRCT scanning is indicated. In the absence of a definitive radiographic pattern, surgical lung biopsy should be considered. CHEST 2009 136, 1397-1405DOI: (10.1378/chest.09-0444) Copyright © 2009 The American College of Chest Physicians Terms and Conditions