Case 2
A 73-year-old woman developed RA at the age of 69 years and had a
history of transient ischemic attack at 67 years of age but no
recurrence. She was prescribed NSAIDS and Chinese herbs by local
physicians. She was hospitalized in our department in March 2021 for
poor disease control. She complained of intermittent arthralgia, morning
stiffness over 2 h daily, and fever, Tmax 38.5℃. Initial
significant findings were tenderness and swelling of the
metacarpophalangeal (MCP) joints of the left 2~5 digit, bilateral
wrists, elbows, shoulders, and fine crackles in bilateral lower lung
fields.
Initial laboratory findings showed that RF, CCP antibody, and ANA were
positive (55.5 IU/mL, >200 U/mL, and 1:3200, respectively),
while ENA and ANCA were negative. CRP and ESR increased to 30.3 mg/L and
50 mm/h, respectively. Markers of the tumor, HBV, and TB were negative.
PFT showed normal ventilatory function and diffusion capacity. The X-ray
revealed few erosions in both hands and wrists. Table 2 showed
the patient’s laboratory findings during the hospitalization. Initial
chest HRCT images showed a typical UIP pattern with marked honeycombing
and traction bronchiectasis in anterior and subpleural upper lobes and
left middle lobe, basal and subpleural right lower lobe, along with few
gross glassy changes, sparing the central part of the lower lobes
(Fig. 1 E, F, G, H, more details seen in Additional
file 2 ). GGO and fibrosis were scored 5 and 10, respectively. Since the
morphological pattern showed UIP with RA, the diagnosis was RA-UIP.
Regarding RA activity, DAS28-CRP scored 4.77 showing moderate disease
activity. The fever was confirmed to be induced by the RA activity,
excluding other conditions such as hypersensitivity pneumonia and
pulmonary infections, and the treatment was initiated with 15 mg of
prednisolone daily tapered by 2.5 mg every month, 5 mg of tofacitinib 2
times daily, and 25 mg of IGU 2 times daily.
She was referred again to assess the therapy 4 months later. The
arthralgia improved gradually and the fever lessened. The prednisolone
dose was 5 mg daily. Tofacitinib 10 mg daily plus IGU 50mg daily were
maintained all the time. The chest HRCT demonstrated that lung lesions
improved (Fig. 1 E1, F1, G1, H1 , more details seen inAdditional file 2 ). Laboratory findings, PFT, and HRCT scores
improved (Table 2 ).
Nevertheless, in November 2021, she developed arthralgia continuously
and coughed intermittently. Disease flares emerged when tofacitinib was
discontinued for unavailablility in the local hospital 1 month after
being discharged, though the prednisolone 5 mg daily plus IGU 50mg daily
was maintained all the time. We observed increased CRP, ESR, worse PFT
and HRCT scores (Table 2 ), and a progressive changes in the
lower lobe of the lung on chest HRCT (Fig. 1 E2, F2, G2, H2 ,
more details seen in Additional file 2 ). Considering that RA
and UIP relapses might result from the unavailable tofacitinib, she was
resumed with 5mg of tofacitinib 2 times daily.
In May 2022, tofacitinib was discontinued again due to the local
outbreak of COVID-19 2 months later. Only the prednisolone 5 mg daily
was maintained all the time. Besides the recurring arthralgia and cough
intermittently, swelling in face and limbs and myalgia in upper limbs
emerged and made her unable to lift her arms over the shoulders. The
disease seemed to flare again (Table 2 ). CRP increased up
to12.4 mg/L, and a progressive shadow in the lower lobe of the lungs
appeared on chest HRCT compared with the previous scan (Fig. 1
E3, F3, G3, H3 , more details seen in Additional file 2 ). Every
time, a rapid arthritis control was obtained with the reintroduction of
tofacitinib and IGU. She continued with 5 mg of prednisolone daily, 5mg
of tofacitinib 2 times daily, and 25mg of IGU 2 times daily and was
prescribed enough for 3 months. So far, she is still being followed-up
with and remains in remission (Table 2 ) of RA-UIP with the
continued use of tofacitinib plus IGU.