A 55-year-old woman known to suffer from severe disabling Rheumatoid arthritis has a 12-month history of dyspnoea.

A 55-year-old woman known to suffer from severe disabling Rheumatoid arthritis has a 12-month history of dyspnoea. She has also had a dry cough for that time. She has never smoked and has never been employed.
Examination shows a woman of average build with severe hand deformities and nodules at the elbow. Cardiovascular examination is normal.
Respiratory examination reveals a diffuse expiratory wheeze.
Routine blood tests, a CXR and an electrocardiogram (ECG) are all normal.

What is the most likely reason for her symptoms?
A. Bronchiolitis obliterans
B. Chronic obstructive pulmonary disease
C. Bronchiectasis
D. Asthma
E. Pleural effusion


Answer:
A-- Bronchiolitis obliterans

Discussion: Rheumatoid arthritis (RA) can affect the lungs in many ways. It is associated with:

• Bronchiectasis
• Pleural effusions
• Lung nodules
• Interstitial fibrosis
• Bronchiolitis obliterans
• Caplan syndrome
• Bronchiolitis obliterans

Bronchiolitis obliterans presents with a non-productive cough and dyspnoea. Physical examination might reveal a diffuse wheeze. The CXR can be normal or can show a miliary or diffuse nodular pattern. Histology will show intraluminal polyps of organising connective tissue.
It is treated with corticosteroids, but the prognosis is poor.

Other causes of bronchiolitis obliterans are:

• toxic fume inhalation, 
• bone marrow transplantation,
• post-lung or post-heart transplantation, 
• infections (viral and Mycoplasma and Legionella spp.),
• penicillamine, 
• systemic lupus erythematosus (SLE) and 
• polymyositis.