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.