Case 1
A 74-year-old woman developed RA in 2010 and had the complication of type 2 diabetes mellitus, but it was stable. She was treated with methotrexate (MTX) 10 mg weekly and 5 mg of prednisolone daily after using sulfasalazine 2000 mg daily and nonsteroidal anti-inflammatory drugs (NSAIDS). In September 2020, she was referred to our department for progressive arthralgia and morning stiffness. Tenderness of the proximal interphalangeal (PIP) joints of the bilateral 2, 3, 5 digits, wrists, knees, right ankle, and fine crackles in left lower lung field were revealed.
Initial laboratory findings showed that he presented with mild anemia. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibody was positive (139.9 IU/mL and >200 U/mL, respectively), while anti-nuclear antibodies (ANA), extractable nuclear antigens (ENA), and antineutrophil cytoplasmic antibodies (ANCA) were negative. C-reactive protein (CRP,30.3 mg/L) and erythrocyte sedimentation rate (ESR,50 mm/h) were both increased. Markers of tumor, Hepatitis B virus (HBV), and Tuberculosis (TB) were negative. The pulmonary function test (PFT) showed normal ventilatory function with mild diffusion capacity impairment. The patient’s laboratory findings during the hospitalization were shown in Table 2 . The X-ray revealed bone erosion in both wrists. Chest HRCT images showed the peripheral regions of the upper and lower lobes are typically involved, basal and subpleural lung dominant reticular opacity, interlobular septal thickness associated with honeycombing and traction bronchiectasis (Fig. 1 A, B, C, D, more details seen inAdditional file 1 ). GGO and fibrosis were scored to assess HRCT findings [16]. GGO and fibrosis were scored 4 and 7, respectively. Since HRCT showed a typical UIP pattern, the diagnosis was RA-UIP.
With a 28-joint count CRP (DAS28-CRP) score of 5.49 showing high disease activity, she was prescribed initially with 15 mg of prednisolone daily, 5mg of tofacitinib 2 times daily, and 25mg of IGU 2 times daily. In May 2021, she visited our outpatient department with relief of arthralgia and morning stiffness. Close examination revealed decreased DAS28-CRP, GGO andfibrosis scores, PFT (Table 2 ), and improved lesions in the lower lobe of her right lung on chest HRCT (Fig. 1 A1, B1, C1, D1 , more details seen in Additional file 1 ). The therapy was highly effective, and the prednisolone dose was reduced by 2.5 mg monthly. During the follow-up, no relapse has been observed to date, and the patent is in good condition without side effects of tofacitinib plus IGU.