Case Presentation: A 50 year old obese female with a past medical history of rheumatoid arthritis, bilateral DVT and PE 4 years ago on apixaban, hypothyroidism, fibromyalgia, and chronic migraines presented to the emergency department with daily fevers, shortness of breath, and anxiety for one week. She reported persistent chest heaviness and productive cough of green sputum. She is a lifetime nonsmoker with no reported alcohol use or recreational drug use. She was recently discharged from our institution less than one month prior with diagnoses of multifocal pneumonia, UTI, and recurrent syncope. She also reported a 30 pound unintentional weight loss. Her daily methotrexate and rituximab were stopped due to recent infection. Physical exam revealed a low grade temperature of 99.5°F, tachypnea, and fine bibasilar crackles. Initial chest CT revealed patchy, nodular bilateral lower lobe and left upper lobe infiltrates. All lab work including CMP, CBC, and urinalysis were within normal limits.
Discussion: Throughout her hospital course, she reported persistent fatigue and shortness of breath with a productive cough of gray-brown mucus. She also began spiking fevers nightly with maximum temperatures of 101°F. She did not improve with empiric antibiotics. Respiratory panel PCR, sputum cultures, and blood cultures were negative. Repeat chest CTs showed worsening pneumonia with migratory waxing and waning central and subpleural infiltrates of ground glass opacities, and the patient required increasing amounts of oxygen via nasal cannula. Due to her deteriorating condition, a bronchoscopy was performed. Biopsy of the lung parenchyma revealed patchy, fibrinous organizing pneumonia with nonspecific interstitial thickening and type II pneumocyte hyperplasia. Her condition improved upon administration of intravenous corticosteroids. Due to persistently negative culture results, steroid-responsiveness, and her history of rheumatoid arthritis, RA-ILD was felt to be the most likely diagnosis. This demonstrates an atypical case of RA-ILD presenting as a productive cough that developed less than one month after withholding her methotrexate and rituximab therapy for her RA. Otherwise, she had many of the classic symptoms of RA-ILD, including fever, fatigue, and weight loss.1 Imaging findings in RA-ILD can be focal or diffuse pulmonary abnormalities most often at the lung periphery, and are typically reticulation, ground-glass opacities, and nodules.1 In this patient, the central and subpleural migratory ground-glass opacities seen in multiple lobes of the lung support our diagnosis of RA-ILD. While RA-ILD typically presents as usual interstitial pneumonia,2 NSIP and OP on the pathologist’s differential strengthened our suspicion that this was likely RA-ILD given that these are the next two most commonly occurring subtypes of RA-ILD.2,3
Conclusions: This case underscores the inclusion of RA-ILD highly on one’s differential diagnosis in patients with comorbid connective tissue disorders who present with pulmonary complaints, particularly in the context of recent modification of their disease-modifying therapy who are not responding to empiric antibiotic therapy. Due to RA-ILD’s increased risk of respiratory, cancer, and all-cause mortality as compared to RA patients without evidence of ILD,4–7 its prompt identification and treatment is a point of emphasis from our report.