Case Presentation: A 50-year-old woman with hypertension presented repeatedly to the emergency department over one year with cough, wheezing, and exertional dyspnea. She was treated on multiple occasions for presumed asthma exacerbations with steroids, antibiotics, and bronchodilators without improvement. Chest radiographs and EKGs were unremarkable.On her sixth visit, she reported progressive throat tightness and hoarseness unrelieved by inhalers. Exam revealed biphasic stridor. Non-contrast CT of the neck demonstrated eccentric subglottic narrowing. Flexible laryngoscopy showed > 75% subglottic narrowing and bronchoscopy confirmed severe subglottic stenosis (SGS) located 1.4 cm below the glottis (0.6 cm in length). She underwent endoscopic coblation excision, intralesional triamcinolone injection, and balloon dilation. Histopathology revealed chronic inflammatory mucosa without granulomas or malignancy.Autoimmune testing showed elevated rheumatoid-factor (74 IU/mL) and anti-cyclic citrullinated peptide antibody (>500 U/mL), with negative ANA, ANCA, and infectious serologies. Chest CT excluded interstitial lung disease. Initially without articular symptoms, she later developed mild exertional fatigue. Rheumatology diagnosed early rheumatoid arthritis (RA) with airway involvement and initiated methotrexate. At one- and three-month follow-up, surveillance laryngoscopy revealed no restenosis. ESR normalized, and the patient achieved clinical remission of RA with sustained airway patency at six months without symptoms.
Discussion: RA is a chronic systemic autoimmune disease affecting approximately 1% of adults, most commonly targeting synovial joints. Airway involvement is rare and usually limited to cricoarytenoid arthritis. SGS as an extra-articular manifestation of RA is rare and can precede classic joint symptoms. It is often mistaken for lower airway disease when it presents with isolated airway complaints. Pathophysiologic mechanisms include immune-mediated perichondritis, vasculitic injury to the subglottic mucosa, and subsequent fibrosis. Unlike post-intubation or granulomatosis with polyangiitis–associated stenosis, RA-related lesions typically lack ulceration or systemic vasculitic features.Diagnostic delay is common because upper airway obstruction can produce “pseudo-wheezing.” When respiratory symptoms fail to respond to bronchodilators or corticosteroids, clinicians should suspect a fixed upper airway lesion. Flexible laryngoscopy and CT imaging are diagnostic cornerstones, while autoimmune serologies help confirm the underlying etiology and guide evaluation for systemic rheumatic disease.For benign SGS, retrospective cohorts suggest that endoscopic dilation combined with intralesional corticosteroid injections prolongs surgery-free intervals compared with dilation alone. Systemic immunosuppression appears to reduce recurrence by controlling the underlying inflammatory process. In our patient, local endoscopic therapy plus initiation of methotrexate achieved durable airway patency and RA remission, highlighting the importance of a coordinated multidisciplinary approach.
Conclusions: RA-associated subglottic stenosis can mimic asthma, leading to misdiagnosis. Hospitalists should suspect a fixed upper airway lesion when respiratory symptoms or wheezing does not improve with bronchodilators or steroids. Early laryngoscopic evaluation and rheumatologic workup are key to preventing delayed diagnosis.