132Lu Rheumatoid Arthritis and Constrictive Bronchiolitis

  • This is a 70 yo F former smoker with PMH significant for difficult to treat seropositive RA (has failed multiple agents; currently on upadacitinib), T2DM, HTN, CKD, COVID-19
  • brief hospitalization 1 year ago and
  • up to 2 lpm supplemental O2)3 months ago
    • dyspnea on exertion following COVID-19 admission4
    • PFTs revealed
      • moderate reduction in DLco and
      • reduction in FVC compared to prior.
    • FEMALE ON METHOTREXATE (RA) WITH NEW BROWNISH PRODUCTIVE COUGH, BILATERAL RHONCHI, ? PNEUMONIA
  • There are no focal consolidations or pleural effusions although there are slightly increased interstitial markings that are chronic.
      • HRCT
        • bilateral subpleural and peribronchovascular reticulations/interstitial thickening,
        • subpleural cystic remodeling in the anterior lobes,
        • bronchiectasis,
        • mosaicism, and
        • possible early cysts in the lower lobes.
        • The fibrotic changes have mildly progressed over 4years.
        • suggestive of constrictive bronchiolitis/OP,
        • follicular bronchiolitis, and
        • LIP among others. At the time of the prior visit (10/14/121),
        • modification of the immunosuppressive regimen to one with lung effect (potentially low dose prednisone and MMF or rituximab); however, given that patient’s RA has been extremely difficult to control, the fact that the CT had demonstrated only mild progression in the fibrotic changes,
        • start nintedanib for progressive fibrosing ILD.
    • Bronchial Wall Thickening
      • Mosaic Attenuation