Scientific Letter
Counterintuitive Pulmonary Nodules in Rheumatoid Arthritis
Nódulos pulmonares contraintuitivos en artritis reumatoide
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A) La TC inicial muestra un nódulo en el lóbulo superior izquierdo con cavitación; B) La TC con mayor resolución del nódulo en el lóbulo superior izquierdo tras 9 meses de seguimiento; C) La TC inicial muestra el nódulo periférico en la língula; D) La TC con mayor resolución del nódulo periférico en la língula tras 9 meses de seguimiento.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Felix Daniel Zamora, Eitan Podgaetz, H. Erhan Dincer" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Felix Daniel" "apellidos" => "Zamora" ] 1 => array:2 [ "nombre" => "Eitan" "apellidos" => "Podgaetz" ] 2 => array:2 [ "nombre" => "H. 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Erhan Dincer" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Felix Daniel" "apellidos" => "Zamora" "email" => array:1 [ 0 => "zamo0038@umn.edu" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Eitan" "apellidos" => "Podgaetz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "H. Erhan" "apellidos" => "Dincer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, United States" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN, United States" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nódulos pulmonares contraintuitivos en artritis reumatoide" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1037 "Ancho" => 1600 "Tamanyo" => 216285 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT of chest (A), initial CT demonstrating left upper lobe nodule with cavitation (B), nine month follow-up CT with resolution of left upper lobe nodule, (C) initial CT demonstrating peripheral nodule in the lingual and (D) nine month follow-up CT with resolution of peripheral nodule in the lingual.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Rheumatoid arthritis (RA) is a significant cause of morbidity and mortality in developed countries, with a prevalence of 0.5%–1% and an incidence of 5–50 per 100<span class="elsevierStyleHsp" style=""></span>000. Nodulosis is the most common extra-articular manifestation and occurs in 25% of RA patients.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> Pulmonary manifestations are broad and include necrobiotic nodules, infections, drug induced lung injury, obliterative bronchiolitis, interstitial lung disease, bronchiectasis, and malignancy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Tumor necrosis factor (TNF) is an overexpressed pro-inflammatory cytokine in RA patients, and the American College of Rheumatology has formal recommendations on the use of anti-TNF biologic agents in RA patients with poor prognostic factors. We report a case of a 50-year-old female developing multifocal nodular consolidations, with and without cavitation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and C), one month after initiation of etanercept. Immunosuppressive drugs were suspended and a bronchoalveolar lavage of the left upper lobe and lingula were negative for an infectious etiology. Devoid of a confirmed infection, her RA medications were restarted, except for etanercept. Serial CT imaging demonstrated interval regression of the nodules. Radiographic changes were seen at the two-month follow up CT, and have remained unchanged at nine months (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B and D).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Etanercept-associated nodular disease case reports have varied from new pulmonary nodules with histopathology typical of pulmonary RA nodules, histopathology consistent with sarcoidosis, and histopathology of lymphohistiocytic infiltrates not typical of either.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> Treatments for etanercept-associated PN have varied, but typically involve corticosteroids and drug withdrawal. There have also been two case reports highlighting the evolution of the nodules with continued etanercept therapy, illustrating the regression of nodules as well as stability of nodules without progression despite continued etanercept therapy.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This case exemplifies that a recombinant human TNF receptor fusion protein may contribute to the counterintuitive formation of granulomatous disease and pulmonary nodulosis. Many mechanisms have been proposed, but the exact mechanism leading to pulmonary nodulosis is not currently known. It has been proposed that the increased size or formation of pulmonary nodules may be related to the increased size of necrotic centers, a result of the reduction of soluble TNF leading to an exaggerated or altered effect on other inflammatory pathways, or even directly related to the RA progression and not directly related to the therapeutic agent.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In conclusion, we appreciate that PN is not uncommon in RA patients, but recommend that etanercept-related PN be considered as part of the differential diagnosis. Bronchoalveolar lavage should remain integral to the evaluation, but if unrevealing it would be reasonable to withhold etanercept followed by repeat imaging in 6–8 weeks. If the nodules are stable or regress, than serial imaging would be a reasonable approach. Progressive disease should be further investigated. Consideration of etanercept as the etiology of new pulmonary nodules may decrease morbidity associated with unnecessary invasive diagnostic procedures associated with nodule work up.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Zamora FD, Podgaetz E, Dincer HE. Nódulos pulmonares contraintuitivos en artritis reumatoide. Arch Bronconeumol. 2016;52:334–335.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1037 "Ancho" => 1600 "Tamanyo" => 216285 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT of chest (A), initial CT demonstrating left upper lobe nodule with cavitation (B), nine month follow-up CT with resolution of left upper lobe nodule, (C) initial CT demonstrating peripheral nodule in the lingual and (D) nine month follow-up CT with resolution of peripheral nodule in the lingual.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "<span class="elsevierStyleBold">References</span>" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Accelerated nodulosis and vasculitis following etanercept therapy for rheumatoid arthritis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. 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Dacic" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/modpathol.3800333" "Revista" => array:6 [ "tituloSerie" => "Mod Pathol" "fecha" => "2005" "volumen" => "18" "paginaInicial" => "651" "paginaFinal" => "655" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15529178" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Marked regression of pulmonary rheumatoid nodules under etanercept therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "G. Derot" 1 => "A. Marini-Portugal" 2 => "B. Maitre" 3 => "P. Claudepierre" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3899/jrheum.080557" "Revista" => array:7 [ "tituloSerie" => "J Rheumatol" "fecha" => "2009" "volumen" => "36" "paginaInicial" => "437" "paginaFinal" => "439" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19208569" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673609612058" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005200000006/v1_201605260126/S157921291500422X/v1_201605260126/en/main.assets" "Apartado" => array:4 [ "identificador" => "49861" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005200000006/v1_201605260126/S157921291500422X/v1_201605260126/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291500422X?idApp=UINPBA00003Z" ]
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| 2019 September | 40 | 13 | 53 |
| 2019 August | 33 | 12 | 45 |
| 2019 July | 32 | 35 | 67 |
| 2019 June | 17 | 33 | 50 |
| 2019 May | 47 | 16 | 63 |
| 2019 April | 50 | 18 | 68 |
| 2019 March | 41 | 21 | 62 |
| 2019 February | 36 | 17 | 53 |
| 2019 January | 30 | 5 | 35 |
| 2018 December | 34 | 17 | 51 |
| 2018 November | 39 | 13 | 52 |
| 2018 October | 83 | 29 | 112 |
| 2018 September | 28 | 13 | 41 |
| 2018 May | 34 | 1 | 35 |
| 2018 April | 29 | 9 | 38 |
| 2018 March | 57 | 4 | 61 |
| 2018 February | 57 | 10 | 67 |
| 2018 January | 122 | 12 | 134 |
| 2017 December | 79 | 5 | 84 |
| 2017 November | 28 | 7 | 35 |
| 2017 October | 11 | 12 | 23 |
| 2017 September | 19 | 6 | 25 |
| 2017 August | 19 | 12 | 31 |
| 2017 July | 17 | 4 | 21 |
| 2017 June | 33 | 13 | 46 |
| 2017 May | 35 | 11 | 46 |
| 2017 April | 44 | 12 | 56 |
| 2017 March | 9 | 14 | 23 |
| 2017 February | 15 | 5 | 20 |
| 2017 January | 11 | 3 | 14 |
| 2016 December | 24 | 19 | 43 |
| 2016 November | 43 | 35 | 78 |
| 2016 October | 42 | 28 | 70 |
| 2016 September | 35 | 9 | 44 |
| 2016 August | 2 | 0 | 2 |
Show all
