alexa Organizing Pneumonia as the First Clinical Manifestation of Early Stage Rheumatoid Arthritis Determined by Hand Joints Synovitis Using Magnetic Resonance Imaging | Open Access Journals
ISSN: 2327-5146
General Medicine: Open Access
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Organizing Pneumonia as the First Clinical Manifestation of Early Stage Rheumatoid Arthritis Determined by Hand Joints Synovitis Using Magnetic Resonance Imaging

Hiroaki Ishikawa1, Yuichi Machishima1, Hiroaki Tachi1, Seiji Mogi1, Ai Hosaka2, Takashi Mamiya2, Taichi Hayashi2, Hideo Terashima3
and Shinji Teramoto2*
1 Department of Internal Medicine, Hitachi, Ltd. Hitachinaka General Hospital, Japan
2 Department of Internal Medicine, Hitachinaka Medical Education and Research Center, The University of Tsukuba, Japan
3 Department of Surgery, Hitachinaka Medical Education and Research Center, The University of Tsukuba, Japan
Corresponding Author : Shinji Teramoto
Hitachinaka Education and Research Center
The University of Tsukuba, Ishikawa-cho 20-1
Hitachinakashi, 312-0057 Ibaraki Japan
Tel: 81-29-354-5926
Fax: 81-29-354-5111
E-mail: [email protected]
Received January 07, 2014; Accepted March 25, 2014; Published April 30, 2014
Citation: Ishikawa H, Machishima Y, Tachi H, Mogi S, Hosaka A, et al. (2014) Organizing Pneumonia as the First Clinical Manifestation of Early Stage Rheumatoid Arthritis Determined by Hand Joints Synovitis Using Magnetic Resonance Imaging. Gen Med (Los Angel) 2:138. doi: 10.4172/2327-5146.1000138
Copyright: © 2014 Ishikawa H, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

We report the case of a 50-year-old man who presented with organizing pneumonia (OP) as the first manifestation of rheumatoid arthritis (RA). He experienced repeated episodes of pneumonia, which did not respond to several antibiotics. The lymphocyte dominant cell increase in the bronchoalveolar lavage fluid on chest computerized tomography suggested OP. Although he did not present with articular symptoms, magnetic resonance imaging (MRI) revealed synovitis of the hand joints without joint erosion, suggesting that this was a case of early stage RA. The MRI may be a useful diagnostic tool in asymptomatic patients with early stage RA.

Keywords
Organizing pneumonia; Rheumatoid arthritis; Joints synovitis; Magnetic resonance imaging
Introduction
There has been increasing recognition of the importance of respiratory disease in patients with rheumatoid arthritis (RA). Interstitial lung disease (ILD) is the only complication of RA that is increasing in prevalence and accounts for approximately 6% of all RA deaths [1]. Organizing pneumonia (OP) is a type of RA-associated interstitial lung diseases (RA-ILD). However, the joint symptoms of RA are usually dominant over the lung alterations in the patients with RA-ILD. Thus, ILD including OP without joint involvement may not be recognized as a sign of RA. Here, we report a case of early stage RA with OP as its first manifestation and accompanied by joint synovitis, which was identified on an MRI scan; MRI has recently become the established method for identification of the insidious joint involvement in RA [2,3].
Case Report
A 50-year-old man with symptoms of sore throat, dry cough, and progressive dyspnea towards the end of March 2011, was treated repeatedly with different antibiotics, including levofloxacin, cefditoren pivoxil, minocycline hydrochloride, and ceftriaxone sodium hydrate; however, his symptoms did not resolve with these drugs. Therefore, he was transferred to our hospital. Although his chest radiographs indicated chronic pulmonary infiltration, his general condition appeared to be good. He had no symptoms of joint involvement, and had never experienced morning stiffness of the hands. His laboratory results upon admission were as follows: white blood cell count, 11,200 cells/μL; C-reactive protein (CRP), 4.59 mg/mL; Mycoplasma IgM antibodies, (-) ; Legionella urinary antigen test (Binax NOW, Portland, ME,USA) (-); QuantiFERON-TB Gold (-); KL-6, 236 U/mL; SP-D, 218 ng/mL. Cultures of blood, sputum, and urine performed on several occasions, were all negative. His chest radiograph showed alveolar exudates with ground-glass opacities in the right lung, accompanied by pleuritis (Figure 1). A high-resolution computed tomography scan showed parenchymal exudates with lung volume loss, suggesting OP of the right lung (Figure 2). An analysis of bronchoalveolar lavage (BAL) fluid revealed lymphocyte dominant cell accumulation in his lungs. The ratio of CD4/CD8 was 4.03. The radiographic examination and BAL analysis were indicative of OP. We initiated treatment with administration of 30 mg of prednisone. The radiographic abnormality was gradually resolved. Because the lung abnormality indicated OP, we took a brief past history and tested for antibodies of possible collagen diseases, which revealed mild symptomatic involvement of the knees. Actually he had slightly symptom of knee joints. We then examined the hand joint abnormality using MRI. The bone cysts of joints and the features of synovial findings of RA were identified on the right hand joints (Figure 3). However, no joint erosion was observed. The RA features were compatible with specific antibody measurements such as anti-CCP antibody level (98.7 U/ml). The other laboratory tests showed normal level of muscle enzymes, ANA (-), anti-SSA (-), anti-SSB (-), Jo-1 (-), RF 37/160, and matrix metalloproteinase-3 (69.8 ng/mL). Orally administered prednisolone improved his insidious joint pain and OP. Pulmonary infiltrates and joint symptoms were improved by 20- 50 mg/day of prednisolone administration. After steroid tapering, no recurrence of pulmonary lesions was observed. However, the knee joint pain was slightly identified. Then steroid therapy still continued with 10-15 mg of prednisolone. The general condition and joint symptoms were well controlled.
Discussion
We present a patient with OP as the first clinical manifestation of early stage RA, identified by the presence of hand synovitis using MRI [2]. His respiratory symptoms, including dyspnea, developed progressively. The patient ignored his mild joint symptoms. The MRI findings of his finger joints suggested that this was a case of early stage RA as the synovitis was not extensive [3]. Furthermore, no signs of joint erosion were present. Recently, the diagnosis of RA has been established by the presence of symptoms with a positive result for anti- CCP antibodies [1,4]. A careful and systematic approach to diagnosis in patients with ILD may reveal an unrecognized RA [5]. However, the disease progression stage may not be determined by the typical antibodies [1,5]. MRI examination of the hand and other joints may therefore be an attractive tool for the disease stage of RA. Imaging plays a significant role in the diagnosis of RA, in detecting inflammation and damage, in predicting the outcome and response to treatment, and monitoring disease activity, progression and remission [2,3].
OP is not only a feature of connective tissue diseases (CTD), but also a feature of various other disorders, including infectious disease and drug-induced lung infiltrates [5-7]. Symptoms of CTDs usually predate lung involvement. OP as the first presentation of CTDs, particularly in RA, is not common [8,9]. The articular symptoms of RA are predominantly observed prior to the occurrence of lung alterations in patients with RA-ILD [1,4]. In some cases, RA is diagnosed several months after the determination of OP or cryptogenic OP [8-10]. Our case also indicates that OP may develop prior to the occurrence of articular symptoms in adult patients with RA. The MRI finding of articular involvement of RA is identified in patients without joint symptoms. In addition to the measurements of specific antibodies for CTDs, the MRI examination of joints is considered a useful modality for the diagnosis and disease assessment of RA.
Importantly, the prognosis of RA is worse when diagnosis and treatment are delayed. Delayed diagnosis of RA-ILD may lead to worsened clinical course [11,12]. Further, Inappropriate treatment and delayed treatment cause joint deformity and degenerative changes of bones [13,14]. The early diagnosis of RA and RA-ILD are important for the mainlining the quality of life of the patients.
In conclusion, in a patient with OP, a brief physical examination including that of joints is necessary. In addition to the measurement of anti-CCP antibodies, MRI examination may hold merit for RA stage assessment.
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