Treatment options for patients with pulmonary fibrosis associated with rheumatoid disease are limited.

Treatment options for patients with pulmonary fibrosis associated with rheumatoid disease are limited. We report a case of a 71-year-old man with a 3-year history of seropositive rheumatoid arthritis (RA) referr to the pulmonary clinic because of progressive pulmonary symptoms associated with radiographic fibrosis that was progressive in spite of corticosteroid treatment. In an attempt to direction his articular symptoms and alter the course of his pulmonary fibrosis, treatment with IV infusion of the tumor necrosis factor (TNF)-[alpha] inhibitor infliximab was initiated. Following 1 year of therapy with this agent, the patient reported sustained improvement in dyspnea, cough and exercise tolerance, in addition to improvement in joint symptoms. Stabilization of pulmonary function was indicated by way of repeat pulmonary function test findings. This report advises that inhibition of TNF-[alpha] may be of significant benefit to patients with fibrosing lung conditions in the setting of RA.

solution words: infliximab; pulmonary fibrosis; tumor necrosis factor-[alpha]

Abbreviations: RA = rheumatoid arthritis; TNF = tumor necrosis factor; UIP = usual interstitial pneumonia

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Pulmonary fibrosis is a devastating lung disorder that is associated with significant morbidity and mortality. (1) Lung fibrosis occurring in rheumatoid arthritis (RA) has exceedingly similar clinical, radiographic, and pathologic characteristics as the idiopathic variety of pulmonary fibrosis that is chiefly commonly attributed to the lesion of usual interstitial pneumonia (UIP). (2) Corticosteroids and other immunosuppressive medications are frequently advocated for therapy despite a lack of controll clinical trials demonstrating objective improvement in lung function or mortality. (13)

Tumor necrosis factor TNF-[alpha] is a proinflammatory cytokine that has been implicated as a solution mediator in the pathophysiology of lung fibrosis. (45) onward the basis of its reported efficacy in the management of RA as a disease-modifying agent, (6) a trial of TNF-[alpha] blockade with infliximab was undertaken in a patient with seropositive RA and pulmonary fibrosis. We describe the case of an individual with RA-associated pulmonary fibrosis who rejoined to treatment with the TNF-[alpha] blocking agent infliximab.

CASE REPORT

A 71-year-old, retired, male farmer received a diagnosis of seropositive RA after developing pain and swelling in hands and wrists 3 years prior to presentation at our clinic. Following a same brief trial of methotrexate, which was discontinued proper to GI intolerance, his rheumatoid disease was managed with low-dose prednisone, hydroxychloroquine, and leflunomide. Approximately a year following the assault of joint symptoms, he noticed the attack of progressive dyspnea on exertion and arid cough that was unresponsive to continued treatment with prednisone. He had no history of pulmonary disease and had no other medical point to be solved [i]or[/i] settleds There was no history of front to any known occupational irritant or birds. He was a former smoker having quit > 40 years prior to presentation, and denied a history of illicit mix with drugs use or alcohol abuse. The patient was receiving the following medications at presentation: prednisone, 5 mg bid; naproxen, 375 mg/d; hydroxychloroquine, 200 mg bid; leflunamide, 20 mg/d; and calcium supplementation.

Physical examination demonstrated mild synovitis in the hands and wrists and rheumatoid nodules through the whole extent of the olecranon bilaterally. Lung examination revealed decreased lung bulks and bilateral fine Velcro-type crepitations bilaterally at the bases.

Laboratory testing demonstrated a mild microcytic anemia, a sedimentation rate of 35/h a rheumatoid factor of 245 (normal, 0 to 39) and a P[Osub2] at tranquillity of 75 mm Hg, which declined to 51 mm Hg following mild exercise. Chest radiography showed reduc lung tomes and diffuse fibrosis with honeycombing. High-resolution CT scan of the chest (Fig 1) showed basilar fibrosis with honeycombing, compatible with UIP. Baseline pulmonary function studies demonstrated a restrictive proces with reduc lung convolutions and moderate reduction in diffusing capacity (Table 1)

[FIGURE 1 OMITTED]

Treatment with the TNF-[alpha] inhibitor infliximab was initiated in view of the persistent synovitis and the demeanor of progressive pulmonary symptoms consistent with the unfolding of rheumatoid-associated pulmonary fibrosis in spite of continued use of prednisone for > 1 year. Infliximab was administered at a dose of 3 mg/kg at time 0 week 2 week 6 and each other 8 weeks thereafter. Following the initial couple infusions of infliximab, marked improvement in joint pains and synovitis occurr With continued treatment, a substantial improvement in dyspnea, exercise tolerance, and cough was reported. Following > 1 year of treatment with infliximab, the patient continues to report sustained improvement in exercise tolerance, and repeat pulmonary function proof findings demonstrate stabilization of pulmonary function (Table 1) Additionally, although oximetric testing demonstrated substantial desaturation with minimal exercise at the time of presentation (decline of oxygen saturation to 84%) follow-up oximetry at 1 year demonstrates a normal saturation at security and a saturation decline to no other than 90% following similar exertion. Although infliximab treatment was well tolerated, oral candidiasis perform the operations indicated ined requiring a short course of fluconazole therapy.

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