Cavitary Lesion in Elderly Patient With Rheumatoid Arthritis: A Diagnostic Challenge

Abstract

INTRODUCTION: Rheumatoid arthritis has multiple affections that may include the lungs. The later are associated with disease stage and progression as well. In his report, we present the case of a male patient with long standing, veneer treated, rheumatoid arthritis presenting with a rather challenging pulmonary complication. CASE PRESENTATION: A 64 years old bedridden male was admitted to the hospital after 5 days of chills, shortness of breath and persistent cough with moderate yellow sputum and left base pleuritic pain. Medical history was remarkable for alcoholism and heavy smoking that quit more than 10 years ago. He had history of rheumatoid arthritis (RA) for more than 20 years never treated, and arterial hypertension (HTN). On admission his temperature was 36 C, blood pressure 87/55 mmHg , pulse 98 bpm, and respiratory rate 22/min with O2 sat at 96%. The white blood cell count was 6.38 (42% neutrophil, 0% band, lymphocyte 38%, monocytes 4.5% and eosinophils 11.8%); the hemoglobin levels was 8.1mg/dL , ESR=24mm, HIV negative, and VDRL negative. The PaO2 at room air was 100 mmHg. A chest X-rays on admission showed bilateral basal infiltrates and left pleural effusion. Patient started on IV antibiotics with minimal clinical response, gram stain of the sputum revealed gram positive cocci, three blood cultures obtained on admission yielded negative. On day 9, patient developed hemoptysis, night fever and sweats. Chest CT scan on day 10 revealed right upper lobe cavity, bilateral emphysematous changes and large loculated fluid collection (abscess). PPD test negative, and second chest CT on day 20 demonstrated multiple irregular shaped cavity lesions at upper lobes, persistent consolidation at the lower lobe with empyema and abscess, and mediastinal adenopathy. DISCUSSION: A cavity has been defined in the radiology literature as “gas filled space within a zone of pulmonary consolidation or within a mass or nodule produced by the expulsion of necrotic part of the lesion via the bronchial treeâ€(1). Cavity lesion is the result of any pathological processes including suppurative necrosis (e.g., pyogenic lung abscess), caseous necrosis (e.g, tuberculosis), ischemic necrosis (e.g, pulmonary infarction), cystic dilatation of the lung structure (e.g, PCP pneumonia), or displacement of lung tissue by cystic structure (e.g, Echicoccocus)(1). Many autoimmune diseases can affect the lung, but cavitation is relatively uncommon in most of these diseases. Rheumatoid arthritis is also commonly associated with pulmonary abnormalities, but cavities due primarily to rheumatoid arthritis are rare (1,2). Lung cavities in patients with rheumatoid arthritis often represent infection or carcinoma, thus, aggressive diagnostic evaluation is warrant for new cavitary lesions in these patients (1-3). CONCLUSIONS: Rheumatoid arthritis (RA) is a generally progressive systemic autoimmune process characterized by chronic symmetrical erosive synovitis. Nonarticular manifestations of RA include subcutaneous nodules, vasculitis, pericarditis, mononeuritis multiplex, and episcleritis (4,5). In rare cases, rheumatoid nodules may appear in the lung and cavitate, presumably due to ongoing vasculitis with ischemic necrosis (1-3).