Case 3
An 83-year-old man, a former smoker (36 pack-years), presented with progressive symmetric arthralgia and morning stiffness at the age of 80, and he underwent ”appendectomy” due to ”appendicitis” in the local hospital in 1984. The patient had been initially treated with the Chinese herbs for 3 months, but the symptoms had not improved significantly, and he was admitted to our department in July 2021. Tenderness and swelling in the PIP 2,3 and MCP 1,2,4 of both hands, wrists, elbows, and shoulders were presented. The auscultation detected fine crackles in both lower lung fields. The patient’s main laboratory findings during the hospitalization were presented in Table 2 .
RA was diagnosed because the RF and ACPA were positive (42 and 300 U/mL, respectively), and arthritis was aggressive and rapidly erosive in the hands and wrists. At chest HRCT, a pattern of UIP was characterized by reticular abnormalities and honeycombing aspects, particularly at the right lower lobe (Fig. 1 I, J, K, L, more details seen inAdditional file 3 ). GGO and fibrosis were scored 4 and 12, respectively.
With DAS28-CRP of 5.26 and FVC% 75.8 showing high disease activity and mild restrictive ventilatory impairment, he was diagnosed as RA-UIP and treated initially with 15 mg of prednisolone daily, 5mg of tofacitinib 2 times daily and 25mg of IGU 2 times daily.
In December 2021, he was reassessed with relief of arthralgia and morning stiffness. Close examination showed a decreased DAS28-CRP, HRCT scores (Table 2 ), and improved lesions in the lower lobe of his lungs on chest HRCT (Fig 1. I1, J1, K1, L1 , more details seen in Additional file 3 ).
In May 2022, he performed the second follow-up and reported a complete resolution of arthralgia. Furthermore, UIP features were kept improved in HRCT (Fig. 1 I2, J2, K2, L2, more details seen inAdditional file 3 ), and DAS28-CRP, PFT, and HRCT scores remained stable over time (Table 2 ). No infections and other adverse events were claimed with continued use of tofacitinib plus IGU.