Case Presentation:
This is a 28‐year‐old female whose past medical history includes juvenile rbeumatoid arthritis, obstructive sleep apnea, hypertension, and congenital blindness. She has been hospitalized twice for evaluation of dyspnea on exertion despite using CPAP. Pulmonary function testing suggested only mild restrictive disease. Stress echocardiogram was normal except for a trivial pericardial effusion. A CT scan of the neck showed changes in the posterior left supraglottic region. The patient's symptoms continued to worsen, culminating in admission to the hospital for dyspnea and cough. She was evaluated with direct laryngoscopy, which demonstrated cricoarytenoid arthritis and false vocal cord involvement with nodules. Ultimately, she underwent tracheostomy, biopsy, and partial excision of a left supraglottic mass lesion. These lesions were found to be rheumatoid nodules.
Discussion:
Rheumatoid arthritis is the most common autoimmune condition, affecting 2% of the general population. It is a systemic disease with extra‐articular manifestations involving many organ systems. Laryngeal involvement in rheumatoid arthritis can involve the cricoarytenoid joint in 17%‐70% of cases. Synovitis, cartilage erosions, and ultimately joint destruction can occur. Laryngeal ankylosis can lead to pulmonary infection, and even death. A less common manifestation of rheumatoid arthritis in the larynx is the development of nodules on the vocal cords. Rheumatoid nodules occur ir about 20% of patients. Commonly located over extensor surfaces of the arms and hands, they have also been described in many other locations including: pleura, lungs, cardiac valves, meninges, and the larynx. Although methotrexate is a highly effective disease‐modifying drug, paradoxically it is known to increase the development of rtieumatoid nodules. However, in most cases, nodules develop secondary to localized vasculitis stemming from uncontrolled inflammation; hence, they are more commonly found in severe, poorly controlled disease. When rheumatoid nodules are localized to the larynx, presenting symptoms frequently include hoarseness, dysphonia, and coughing. Diagnosis of laryngeal involvement in rheumatoid arthritis is made by CT scan or direct visualization via laryngoscopy. Treatment involves high‐dose corticosteroids for cricoarytenoid arthritis, removal of rheumatoid nodules by laryngoscopy, and occasionally tracheostomy in severe cases.
Conclusions:
Physicians are generally familiar with the peripheral joint findings and common manifestations of rbeumatoid arthritis such as pericarditis. Other extra‐articular manifestations such as rheumatoid nodules, secondary vasculitis, and arthritis in less commonly involved joints such as the cricoarytenoid joints are less well appreciated. Awareness of these manifestations can lead to earlier diagnosis in patients with severe rheumatoid arthritis presenting with symptoms of respiratory insufficiency or airway obstruction.
Author Disclosure:
R. Eubanks, none; R. Fasheh, none; A. Varanasi, none: R. Rieti, none.