OA19 A complex case of bilateral pneumothoraces due to probable certolizumab driven rheumatoid lung nodules

• Published in: Rheumatology advances in practice 2023-09, Vol.7 (Supplement_2)
• Main Authors: Ahmed, Sajeel, Aujayeb, Avinash, Thompson, Ben
• Format: Article
• Language: English
• Subjects: Oral Presentations
• ISSN: 2514-1775; 2514-1775
• DOI: 10.1093/rap/rkad070.019

Abstract Introduction Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease with articular and extra-articular manifestations. The skin is the most common site of extra-articular involvement and subcutaneous nodules are evident in 25% of RA patients. These are granulomatous nodules often found at extensor surfaces but have also been reported in the menisci, the heart and the lungs. In contrast to rheumatoid nodules, accelerated nodules have a quicker onset and growth and adopt a different dissemination pattern. The case presented here is a patient with seropositive RA who developed accelerated nodulosis likely with the use of certolizumab and consequently required complex intervention. Case description A 31-year-old woman, with a background of seropositive (anti-CCP 261 and RF 30), non-erosive rheumatoid arthritis (RA) diagnosed 6 years ago and recent onset of subcutaneous nodules presented with a large right sided spontaneous pneumothorax. She was a never smoker and had no significant family history. She had been on certolizumab 200mg fortnightly via subcutaneous injection for 18 months, hydroxychloroquine 200mg once a day and leflunomide 20mg once a day for 3 years and had trialled methotrexate 3 years previously. With the premise that this was a primary pneumothorax, ambulatory management was initiated with an 8FG Rocket® Pleural Vent™. A repeat CXR showed a small right residual pneumothorax, a new small left pneumothorax and a subtle cavitatory lesion. A chest computed tomogram (CT) showed bilateral small pneumothoraces and cavitating lesions in both lungs. There was no associated lymphadenopathy or pulmonary emboli. The differential diagnoses of such lesions included infection, infarcts, disseminated malignancy and in her case, rheumatoid lung nodules. A chest radiograph done 6 months before the above presentation was normal. Given the rapid appearance of her pulmonary nodules, she was felt to have accelerated nodulosis, potentially secondary to certolizumab or less likely, leflunomide. Due to a persisting air leak, a right-sided video-assisted thoracoscopy, bullectomy, talc pleurodesis and nodule resection was performed. She then presented with a large left sided pneumothorax and similar surgery was also performed. She required prolonged antibiotics and ambulatory drainage due to post-operative empyema. Histology of the cavitatory lesions showed multiple aggregate necrobiotic granulomatous areas surrounded by histiocytes and chronic i