Case 35--Cavitary Nodules in a Man with Rheumatoid Arthritis

Clinical summary: A 65-year-old man was seen in consultation by the chest service on 12/3 for cavitating pulmonary nodules. There was a history of severe, deforming rheumatoid arthritis for over 25 years, for which he had undergone multiple surgical procedures on his ankles, knees, and hands. Past therapeutic agents, all of which were deemed ineffective, included imuran, sulfasalazine, plaquenil, and methotrexate. He had been taking prednisone (5-15 mg/day) for many years. Three months ago, etanercept was begun, and, miraculously, his arthritic pain and swelling of his hands and knees had diminished. Over the past 6 months, he had developed a progressively worsening cough, occasionally productive of yellow sputum, but no hemoptysis. Over the same period, he also developed dyspnea after walking about one block. He denied pleurisy, fever, chills, night sweats, and weight loss. His past medical history included adult-onset diabetes mellitus, dilated cardiomyopathy, and a positive PPD test 20 years ago, for which he took INH for a year. He smoked cigarettes for 6 years but quit 15 years ago. He is retired from work as a missile mechanic. He denied work in a dusty environment, specifically, asbestos, coal, and silica. On physical examination, his vital signs were normal and he was comfortable at rest. Chronic, symmetric, deforming polyarthritis was present with moderate synovitis of the metacarpophalangeal joints. Joints were cool and without effusions. The skin showed no evidence of vasculitis or nodules. The lungs had crackles at the left base. There were no wheezes.

Laboratory tests: Sputum cultures were negative for organisms including acid fast bacilli. Liver function tests were normal. BUN and creatinine were normal, and a urinalysis was negative.

Pulmonary Function Testing

Predicted

Actual

% Predicted

FVC (L)

3.87

1.92

50

FEV1 (L)

2.71

1.53

56

FEV1/FVC (%)

70

80

114

FEF25-75% (L/S)

2.86

1.40

49

Dsb ml/min/mmHg

25.87

8.63

33

What is your interpretation? Answer

A chest CT performed 11/23 was reviewed.

Radiology | Image 1 | Image 2 | Image 3 | Image 4 | Image 5 | Image 6 | Image 7 | Discussion

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Answer:

Predicted

Actual

% Predicted

FVC (L)

3.87

1.92

50

FEV1 (L)

2.71

1.53

56

FEV1/FVC (%)

70

80

114

FEF25-75% (L/S)

2.86

1.40

49

Dsb ml/min/mmHg

25.87

8.63

33

The parallel reduction in FVC and FEV1 suggests a restrictive ventilatory defect. The decrease in FEF25-75% indicates mild airway obstruction. There was no significant reversal of obstruction following an inhaled bronchodilator. The marked decrease in diffusing capacity suggests loss of capillary surface area, which may be seen in pulmonary fibrosis, emphysema, or pulmonary vascular disease.

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