Pulmonary Manifestations of Rheumatoid Arthritis

ABSTRACT

Rheumatoid arthritis (RA) is a systemic disease, characterized by symmetric joint involvement, but it can also affect other organ systems, including the lungs. The better-known pulmonary manifestations of RA are interstitial lung disease, rheumatoid nodules, and pleural effusions. Less common manifestations include bronchiolitis obliterans and crycoarytenoid arthritis. Management of these conditions involves, by and large, supportive pulmonary care and control of the underlying articular process. Other pulmonary manifestations in RA patients can ensue as a result of the treatments used for it, mainly methotrexate. This article discusses the most common pulmonary manifestations of RA and their treatment. A discussion about the increasing impact that cigarette smoking is having on RA is also provided.

KEYWORDS

Rheumatoid arthritis - lungs - pleura

REFERENCES

• 1 MacGregor A J, Silman A J. Rheumatoid arthritis and other synovial disorders. Classification and epidemiology. In: Hochberg MC, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH Rheumatology 3rd ed. St. Louis; Mosby 2003: 757-763
• 2 Nepom G T. Major histocompatibility complex-directed susceptibility to rheumatoid arthritis.  Adv Immunol. 1998;  68 315-332
• 3 Albert L J. Infection and rheumatoid arthritis: guilt by association?.  J Rheumatol. 2000;  27 564-566
• 4 Fox D A. Etiology and pathogenesis of rheumatoid arthritis. In: Koopman WJ, Moreland LW Arthritis and Allied Conditions 15th ed. Baltimore; Lippincott, Williams and Wilkins 2005: 1089-1115
• 5 Turesson C, O'Fallon W M, Crowson C S, Gabriel S E, Matteson E L. Extra-articular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years.  Ann Rheum Dis. 2003;  62 722-727
• 6 Mattey D L, Dawes P T, Fisher J et al.. Nodular disease in rheumatoid arthritis: association with cigarette smoking and HLA-DRB1/TNF gene interaction.  J Rheumatol. 2002;  29 2313-2318
• 7 Criswell L A, Merlino L A, Cerhan J R et al.. Cigarette smoking and the risk of rheumatoid arthritis among postmenopausal women: results from the Iowa Women's Health Study.  Am J Med. 2002;  112 465-471
• 8 Bas S, Perneger T V, Seitz M et al.. Diagnostic tests for rheumatoid arthritis: comparison of anti-cyclic citrullinated peptide antibodies, anti-keratin antibodies and IgM rheumatoid factors.  Rheumatology (Oxford). 2002;  41 809-814
• 9 Hoving J L, Buchbinder R, Hall S et al.. A comparison of magnetic resonance imaging, sonography, and radiography of the hand in patients with early rheumatoid arthritis.  J Rheumatol. 2004;  31 663-675
• 10 O'Dell J R. Therapeutic strategies for rheumatoid arthritis.  N Engl J Med. 2004;  350 2591-2602
• 11 Vessey M P, Villard-Mackintosh L, Yeates D. Oral contraceptives, cigarette smoking and other factors in relation to arthritis.  Contraception. 1987;  35 457-464
• 12 Heliovaara M, Aho K, Aromaa A, Knekt P, Reunanen A. Smoking and risk of rheumatoid arthritis.  J Rheumatol. 1993;  20 1830-1835
• 13 Costenbader K H, Feskanich D, Mandl L A, Karlson E W. Smoking intensity, duration, and cessation, and the risk of rheumatoid arthritis in women.  Am J Med. 2006;  119 503 e1-9
• 14 Hutchinson D, Shepstone L, Moots R, Lear J T, Lynch M P. Heavy cigarette smoking is strongly associated with rheumatoid arthritis (RA), particularly in patients without a family history of RA.  Ann Rheum Dis. 2001;  60 223-227
• 15 Manfredsdottir V F, Vikingsdottir T, Jonsson T et al.. The effects of tobacco smoking and rheumatoid factor seropositivity on disease activity and joint damage in early rheumatoid arthritis.  Rheumatology (Oxford). 2006;  45 734-740
• 16 Nyhall-Wahlin B M, Jacobsson L T, Petersson I F, Turesson C. BARFOT study group: smoking is a strong risk factor for rheumatoid nodules in early rheumatoid arthritis.  Ann Rheum Dis. 2006;  65 601-606
• 17 Harrison B J, Silman A J, Wiles N J, Scott D G, Symmons D P. The association of cigarette smoking with disease outcome in patients with early inflammatory polyarthritis.  Arthritis Rheum. 2001;  44 323-330
• 18 Saag K G, Kolluri S, Koehnke R K et al.. Rheumatoid arthritis lung disease: determinants of radiographic and physiologic abnormalities.  Arthritis Rheum. 1996;  39 1711-1719
• 19 Struthers G R, Scott D L, Delamere J P, Sheppeard H, Kitt M. Smoking and rheumatoid vasculitis.  Rheumatol Int. 1981;  1 145-146
• 20 Michnovicz J J, Hershcopf R J, Naganuma H, Bradlow H L, Fishman J. Increased 2-hydroxylation of estradiol as a possible mechanism for the anti-estrogenic effect of cigarette smoking.  N Engl J Med. 1986;  315 1305-1309
• 21 Gorman J D. Smoking and rheumatoid arthritis: another reason to just say no.  Arthritis Rheum. 2006;  54 10-13
• 22 Firestein G S, Echeverri F, Yeo M, Zvaifler N J, Green D R. Somatic mutations in the p53 tumor suppressor gene in rheumatoid arthritis synovium.  Proc Natl Acad Sci USA. 1997;  94 10895-10900
• 23 Albano S A, Santana-Sahagun E, Weisman M H. Cigarette smoking and rheumatoid arthritis.  Semin Arthritis Rheum. 2001;  31 146-159
• 24 Klareskog L, Stolt P, Lundberg K et al.. A new model for an etiology of rheumatoid arthritis: smoking may trigger HLA-DR (shared epitope)-restricted immune reactions to autoantigens modified by citrullination.  Arthritis Rheum. 2006;  54 38-46
• 25 Scadding J G. The lungs in rheumatoid arthritis.  Proc R Soc Med. 1969;  62 227-238
• 26 Tanoue L T. Pulmonary manifestations of rheumatoid arthritis.  Clin Chest Med. 1998;  19 667-686
• 27 Gabbay E, Tarala R, Will R et al.. Interstitial lung disease in recent onset rheumatoid arthritis.  Am J Respir Crit Care Med. 1997;  156 528-535
• 28 Morrison S C, Mody G M, Benatar S R, Meyers O L. The lungs in rheumatoid arthritis: a clinical, radiographic and pulmonary function study.  S Afr Med J. 1996;  86 829-833
• 29 Walker W C, Wright V. Pulmonary lesions and rheumatoid arthritis.  Medicine. 1968;  47 501-520
• 30 DeHoratius R J, Abruzzo J L, Williams R C. Immunofluorescent and immunologic studies of rheumatoid lung.  Arch Intern Med. 1972;  129 441-446
• 31 DeHoratius R J, Williams R C. Rheumatoid factor accentuation of pulmonary lesions associated with experimental diffuse proliferative lung disease.  Arthritis Rheum. 1972;  15 293-301
• 32 Cervantes-Perez P, Toro-Perez A H, Rodriguez-Jurado P. Pulmonary involvement in rheumatoid arthritis.  JAMA. 1980;  243 1715-1719
• 33 Payne C R. Pulmonary manifestations of rheumatoid arthritis.  Br J Hosp Med. 1984;  32 192-197
• 34 Fujii M, Adachi S, Shimizu T et al.. Interstitial lung disease in rheumatoid arthritis: assessment with high-resolution computed tomography.  J Thorac Imaging. 1993;  8 54-62
• 35 Garcia J GN, Parhami N, Killam D et al.. Bronchoalveolar lavage fluid evaluation in rheumatoid arthritis.  Am Rev Respir Dis. 1986;  133 450-454
• 36 Haslam P L, Turton C WG, Heard B et al.. Bronchoalveolar lavage in pulmonary fibrosis: comparison of cells obtained with lung biopsy and clinical features.  Thorax. 1980;  35 9-18
• 37 Rajasekaran A, Shonlin D, Saravanan V, Lord P, Kelly C. Interstitial lung disease in patients with rheumatoid arthritis: comparison with cryptogenic fibrosing alveolitis over 5 years.  J Rheumatol. 2006;  33 1250-1253
• 38 Cortet B, Flipo R M, Remy-Jardin M et al.. Use of high resolution computed tomography of the lungs in patients with rheumatoid arthritis.  Ann Rheum Dis. 1995;  54 815-819
• 39 Yousem S A, Colby T V, Carrington C B. Lung biopsy in rheumatoid arthritis.  Am Rev Respir Dis. 1985;  131 770-777
• 40 Feigin D S. Vasculitis in the lung.  J Thorac Imaging. 1988;  3 33-48
• 41 Yue C C, Park C H, Kushner I. Apical fibrocavitary lesions of the lung in rheumatoid arthritis.  Am J Med. 1986;  81 741-746
• 42 Petrie G R, Bloomfield P, Grant I WB et al.. Upper lobe fibrosis and cavitation in rheumatoid disease.  Br J Dis Chest. 1980;  74 263-267
• 43 Cohen A J, King T E, Downey G P. Rapidly progressive bronchiolitis obliterans with organizing pneumonia.  Am J Respir Crit Care Med. 1994;  149 1670-1675
• 44 Geddes D M, Corrin B, Brewerton D A et al.. Progressive airway obliteration in adults and its association with rheumatoid disease.  QJM. 1977;  184 427-444
• 45 Schwarz M I, Lynch D A, Tuder R. Bronchiolitis obliterans: the lone manifestation of rheumatoid arthritis?.  Eur Respir J. 1994;  7 817-820
• 46 Herzog C A, Miller R R, Hoiadel J R. Bronchiolitis and rheumatoid arthritis.  Am Rev Respir Dis. 1981;  124 636-639
• 47 Hillarby M C, McMahon M J, Grennan D M et al.. HLA association in subjects with rheumatoid arthritis and bronchiectasis but not with other pulmonary complications of rheumatoid disease.  Br J Rheumatol. 1993;  32 794-797
• 48 Lofgren R H, Montgomery W W. Incidence of laryngeal involvement in rheumatoid arthritis.  N Engl J Med. 1962;  267 193-195
• 49 Balbir-Gurman A, Yigla M, Nahir A M, Braun-Moscovici Y. Rheumatoid pleural effusion.  Semin Arthritis Rheum. 2006;  35 368-378
• 50 Hakala M, Tiilikainen A, Hameenkorpi R et al.. Rheumatoid arthritis with pleural effusion includes a subgroup with autoimmune features and HLA-B8, DW3 association.  Scand J Rheumatol. 1986;  15 290-296
• 51 Lillington G A, Carr D T, Mayne J G. Rheumatoid pleurisy with effusion.  Arch Intern Med. 1971;  128 764-768
• 52 Mathew P K. Pericardial tamponade secondary to sudden steroid withdrawal in chronic rheumatoid arthritis.  Chest. 1977;  72 532-534
• 53 Ayzenberg O, Reiff D B, Levin L. Bilateral pneumothoraces and pleural effusions complicating rheumatoid lung disease.  Thorax. 1983;  38 159-160
• 54 Shiel Jr W C, Prete P E. Pleuropulmonary manifestations of rheumatoid arthritis.  Semin Arthritis Rheum. 1984;  13 235-243
• 55 Sundy J S. Nonsteroidal anti-inflammatory drugs. In: Koopman WJ, Moreland LW Arthritis and Allied Conditions 15th ed. Baltimore; Lippincott, Williams and Wilkins 2005: 679-704
• 56 Goodwin S D, Glenny R W. Nonsteroidal anti-inflammatory drug-associated pulmonary infiltrates with eosinophilia: review of the literature and Food and Drug Administration Adverse Drug Reaction reports.  Arch Intern Med. 1992;  152 1521-1524
• 57 Heffner J E, Sahn S A. Salicylate-induced pulmonary edema: clinical features and prognosis.  Ann Intern Med. 1981;  95 405-409
• 58 Turner-Warwick M. Adverse reactions affecting the lung: possible association with D-penicillamine.  J Rheumatol Suppl. 1981;  7 166-168
• 59 Eastmond C J. Diffuse alveolitis as complication of penicillamine treatment for rheumatoid arthritis.  BMJ. 1976;  1 1506
• 60 Tomioka R, King Jr T E. Gold-induced pulmonary disease: clinical features, outcome, and differentiation from rheumatoid lung disease.  Am J Respir Crit Care Med. 1997;  155 1011-1020
• 61 Sawitzke A D, Cannon G W. Immunomodulatory agents (cyclosporine, tacrolimus, azathioprine, cyclophosphamide, mycophenolate mofetil, and chlorambucil). In: Koopman WJ, Moreland LW Arthritis and Allied Conditions 15th ed. Baltimore; Lippincott, Williams and Wilkins 2005: 885-913
• 62 Ostor A J, Chilvers E R, Somerville M F et al.. Pulmonary complications of infliximab therapy in patients with rheumatoid arthritis.  J Rheumatol. 2006;  33 622-628
• 63 Villeneuve E, St-Pierre A, Haraoui B. Interstitial pneumonitis associated with infliximab therapy.  J Rheumatol. 2006;  33 1189-1193
• 64 Huggett M T, Armstrong R. Adalimumab-associated pulmonary fibrosis.  Rheumatology (Oxford). 2006;  45 1312-1313
• 65 Schoe A, van der Laan-Baalbergen N E, Huizinga T W, Breedveld F C, van Laar J M. Pulmonary fibrosis in a patient with rheumatoid arthritis treated with adalimumab.  Arthritis Rheum. 2006;  55 157-159
• 66 Farber S, Diamond L K, Mercer R D, Sylvester R F, Wolff J A. Temporary remissions in acute leukemia in children produced by folic acid antagonist, 4-aminopteroyl-glutamic acid (aminopterin).  N Engl J Med. 1948;  238 787-793
• 67 Gubner R, August S, Ginsberg V. Therapeutic suppression of tissue reactivity, II: Effect of aminopterin in rheumatoid arthritis and psoriasis.  Am J Med Sci. 1951;  221 176-182
• 68 Perry M C, Anderson C M, Donehower R C. Chemotherapy. In: Abeloff MD, Armitage JO, Niederhuber JC, Kastan MB, Mc Kenna WG Clinical Oncology. Edinburgh; Churchill Livingstone 2004: 494
• 69 Cannon G W, Ward J R, Clegg D O, Samuelson Jr C O, Abbott T M. Acute lung disease associated with low-dose pulse methotrexate therapy in patients with rheumatoid arthritis.  Arthritis Rheum. 1983;  26 1269-1274
• 70 Hilliquin P, Renoux M, Perrot S, Puechal X, Menkes C J. Occurrence of pulmonary complications during methotrexate therapy in rheumatoid arthritis.  Br J Rheumatol. 1996;  35 441-445
• 71 Alarcón G S, Kremer J M, Macaluso M et al.. Risk factors for methotrexate-induced lung injury in patients with rheumatoid arthritis. A multicenter, case-control study. Methotrexate-Lung Study Group.  Ann Intern Med. 1997;  127 356-364
• 72 Carroll G J, Thomas R, Phatouros C C et al.. Incidence, prevalence and possible risk factors for pneumonitis in patients with rheumatoid arthritis receiving methotrexate.  J Rheumatol. 1994;  21 51-54
• 73 Golden M R, Katz R S, Balk R A, Golden H E. The relationship of preexisting lung disease to the development of methotrexate pneumonitis in patients with rheumatoid arthritis.  J Rheumatol. 1995;  22 1043-1047
• 74 Ohosone Y, Okano Y, Kameda H et al.. Clinical characteristics of patients with rheumatoid arthritis and methotrexate induced pneumonitis.  J Rheumatol. 1997;  24 2299-2303
• 75 Kremer J M, Alarcón G S, Weinblatt M E et al.. Clinical, laboratory, radiographic, and histopathologic features of methotrexate-associated lung injury in patients with rheumatoid arthritis: a multicenter study with literature review.  Arthritis Rheum. 1997;  40 1829-1837
• 76 Inokuma S, Kono H, Kohno Y et al.. Methotrexate-induced lung injury in patients with rheumatoid arthritis occurs with peripheral blood lymphocyte count decrease.  Ann Rheum Dis. 2006;  65 1113-1114
• 77 Salaffi F, Manganelli P, Carotti M, Subiaco S, Lamanna G, Cervini C. Methotrexate-induced pneumonitis in patients with rheumatoid arthritis and psoriatic arthritis: report of five cases and review of the literature.  Clin Rheumatol. 1997;  16 296-304
• 78 Schnabel A, Dalhoff K, Bauerfeind S, Barth J, Gross W L. Sustained cough in methotrexate therapy for rheumatoid arthritis.  Clin Rheumatol. 1996;  15 277-282
• 79 Beyeler C, Jordi B, Gerber N J, Im Hof V. Pulmonary function in rheumatoid arthritis treated with low-dose methotrexate: a longitudinal study.  Br J Rheumatol. 1996;  35 446-452
• 80 Dayton C S, Schwartz D A, Sprince N L et al.. Low-dose methotrexate may cause air trapping in patients with rheumatoid arthritis.  Am J Respir Crit Care Med. 1995;  151 1189-1193
• 81 Dawson J K, Graham D R, Desmond J, Fewins H E, Lynch M P. Investigation of the chronic pulmonary effects of low-dose oral methotrexate in patients with rheumatoid arthritis: a prospective study incorporating HRCT scanning and pulmonary function tests.  Rheumatology (Oxford). 2002;  41 262-267
• 82 Schnabel A, Richter C, Bauerfeind S, Gross W L. Bronchoalveolar lavage cell profile in methotrexate induced pneumonitis.  Thorax. 1997;  52 377-379
• 83 Fuhrman C, Parrot A, Wislez M et al.. Spectrum of CD4 to CD8 T-cell ratios in lymphocytic alveolitis associated with methotrexate-induced pneumonitis.  Am J Respir Crit Care Med. 2001;  164 1186-1191
• 84 Khadadah M E, Jayakrishnan B, Al-Gorair S et al.. Effect of methotrexate on pulmonary function in patients with rheumatoid arthritis - a prospective study.  Rheumatol Int. 2002;  22 204-207
• 85 Cottin V, Tebib J, Massonnet B, Souquet P J, Bernard J P. Pulmonary function in patients receiving long-term low-dose methotrexate.  Chest. 1996;  109 933-938
• 86 Saravanan V, Kelly C A. Reducing the risk of methotrexate pneumonitis in rheumatoid arthritis.  Rheumatology (Oxford). 2004;  43 143-147
• 87 Guidelines for monitoring drug therapy in rheumatoid arthritis. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines.  Arthritis Rheum. 1996;  39 723-731
• 88 Libby D, White D A. Pulmonary toxicity of drugs used to treat systemic autoimmune diseases.  Clin Chest Med. 1998;  19 809-821
• 89 Suwa A, Hirakata M, Satoh S, Mimori T, Utsumi K, Inada S. Rheumatoid arthritis associated with methotrexate-induced pneumonitis: improvement with i.v. cyclophosphamide therapy.  Clin Exp Rheumatol. 1999;  17 355-358
• 90 Roschmann R A, Rothenberg R J. Pulmonary fibrosis in rheumatoid arthritis: a review of clinical features and therapy.  Semin Arthritis Rheum. 1987;  16 174-185
• 91 Walker W C, Wright V. Pulmonary lesions and rheumatoid arthritis.  Medicine (Baltimore). 1968;  47 501-520
• 92 Scott D G, Bacon P A. Response to methotrexate in fibrosing alveolitis associated with connective tissue disease.  Thorax. 1980;  35 725-731
• 93 Chang H K, Park W, Ryu D S. Successful treatment of progressive rheumatoid interstitial lung disease with cyclosporine: a case report.  J Korean Med Sci. 2002;  17 270-273
• 94 Puttick M P, Klinkhoff A V, Chalmers A, Ostrow D N. Treatment of progressive rheumatoid interstitial lung disease with cyclosporine.  J Rheumatol. 1995;  22 2163-2165
• 95 Cohen J M, Miller A, Spiera H. Interstitial pneumonitis complicating rheumatoid arthritis: sustained remission with azathioprine therapy.  Chest. 1977;  72 521-524
• 96 Vassallo R, Matteson E, Thomas Jr C F. Clinical response of rheumatoid arthritis-associated pulmonary fibrosis to tumor necrosis factor-alpha inhibition.  Chest. 2002;  122 1093-1096
• 97 Turesson C, Matteson E L. Management of extra-articular disease manifestations in rheumatoid arthritis.  Curr Opin Rheumatol. 2004;  16 206-211
• 98 Chapman P T, O'Donnell J L, Moller P W. Rheumatoid pleural effusion: response to intrapleural corticosteroid.  J Rheumatol. 1992;  19 478-480
• 99 Russell M L, Gladman D D, Mintz S. Rheumatoid pleural effusion: lack of response to intrapleural corticosteroid.  J Rheumatol. 1986;  13 412-415