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.