CHEST Guidelines-A-48-Year-Old-South-African-Woman-with-Rheumatoid-

A-48-Year-Old-South-African-Woman-with-Rheumatoid-

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The document presents a medical case study of a 48-year-old South African woman with rheumatoid arthritis and lung nodules. This patient, with no smoking history, was initially diagnosed with seropositive rheumatoid arthritis in 2001, which was managed with chloroquine and methotrexate until she developed a disease flare in 2015. Her medication was changed to leflunomide due to cost constraints limiting access to biologic agents.<br /><br />In May 2018, she experienced new symptoms of dyspnea and a dry cough. Examination revealed active synovitis and specific lung abnormalities, including numerous bilateral asymmetrical lung nodules with central cavitation as per high-resolution CT imaging. Initial examinations, including blood tests and bronchoalveolar lavage (BAL), were conducted to rule out infections, including tuberculosis (TB), given her immunosuppression and the high prevalence of TB in South Africa. A single test showed low-level TB positivity, prompting a temporary course of anti-TB therapy, which was later halted due to drug-induced liver injury and worsening arthritis, with final tests returning negative for TB.<br /><br />The case discusses the challenge of diagnosing pulmonary nodules, with a focus on differentiating rheumatoid pulmonary nodules, which can mimic malignancy or infection. A trans-Atlantic consultation led to a consensus that the nodules were rheumatoid in nature, supported by specific CT imaging features and the patient’s clinical background.<br /><br />The patient was treated with prednisone and chloroquine; after three months, her condition improved, evidenced by reduced lung nodules and resolution of liver injury. Thereafter, special approval was obtained for rituximab therapy due to limited access to biologic agents in South Africa. The case emphasizes careful consideration of diagnostic tests' accuracy within the context of varying disease prevalence.

Keywords

rheumatoid arthritis

lung nodules

South African patient

dyspnea

synovitis

tuberculosis

diagnostic challenge

pulmonary nodules

rituximab therapy

immunosuppression