rspНаучно-практическая ревматологияRheumatology Science and Practice1995-44841995-4492IMA-PRESS, LLC10.14412/1995-4484-2019-349-355rsp-2738Research ArticleКЛИНИЧЕСКОЕ НАБЛЮДЕНИЕCLINICAL OBSERVATIONSРевматоидные узлы в паренхиме легких при ревматоидном артритеRheumatoid nodules in the lung parenchyma in rheumatoid arthritisСатыбалдыевА. М.SatybaldyevA. M.

115522, Москва, Каширское шоссе, 34А.

34A, Kashirskoe Shosse, Moscow 115522.

azamatsat@yandex.ruАнаньеваЛ. П.AnanyevaL. P.

115522, Москва, Каширское шоссе, 34А.

34A, Kashirskoe Shosse, Moscow 115522.

ФГБНУ «Научно-исследовательский институт ревматологии им. В.А. Насоновой»РоссияV.A. Nasonova Research Institute of RheumatologyRussian Federation201911072019573349355Copyright © Сатыбалдыев А.М., Ананьева Л.П., 20192019Сатыбалдыев А.М., Ананьева Л.П.Satybaldyev A.M., Ananyeva L.P.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://rsp.mediar-press.net/rsp/article/view/2738

Ревматоидные узелки (РУ) относятся к числу наиболее частых внесуставных проявлений ревматоидного артрита (РА), но редко локализуются в легочной ткани. Развитие внесуставных (системных) проявлений РА ассоциируется с присутствием высоких концентраций ревматоидного фактора и антител к циклическому цитруллинированному пептиду. Особенностью течения РУ в легочной ткани является нередкое их возникновение при минимально выраженных воспалительных изменениях в суставах или ремиссии. В редких случаях РУ подвергаются распаду и нагноению, которые могут осложниться образованием небольших каверн, кровохарканьем, а при субплевральной локализации – пневмотораксом. Кроме того, имеются публикации о возможной связи образования и ускорения развития РУ с приемом иммуносупрессивных препаратов (метотрексата, тоцилизумаба, D-пеницилламина, солей золота, лефлуномида, инфликсимаба и других ингибиторов фактора некроза опухоли α) и о связи РУ легочной локализации с лечением метотрексатом. Представлено клиническое наблюдение больной с overlap-синдромом – сочетанием РА и системной склеродермии, с развитием РУ в легочной ткани в ранние сроки от начала заболевания, когда уже был достигнут целевой уровень активности РА (по DAS28). Атипичная конфигурация узла в легком потребовала дифференциально-диагностического поиска. Демонстрируются результаты визуализации РУ в легких и их динамика. Обсуждаются представленные данные.

Rheumatoid nodules (RNs) are one of the most common extra-articular manifestations of rheumatoid arthritis (RA), but are rarely located in lung tissue. The development of extra-articular (systemic) manifestations of RA is associated with the high levels of rheumatoid factor and anticyclic citrullinated peptide antibodies. The specific features of the course of RNs in lung tissue are their frequent occurrence with minimally pronounced joint inflammatory changes or remission. In rare cases, RNs are prone to disintegration and suppuration, which may be complicated by the formation of small caverns, hemoptysis, and, if located subpleurally, pneumothorax. In addition, there are publications on the possible relationship of the formation of RNs and their accelerated development to the administration of immunosuppressive drugs (methotrexate, tocilizumab, D-penicillamine, gold salts, leflunomide, infliximab, and other TNF-α inhibitors) and on the association of pulmonary RNs with methotrexate treatment. The paper describes a clinical case of a female patient with RA-systemic sclerosis overlap syndrome and RN formation in lung tissue early at disease onset when the DAS28 target level for RA has been achieved. The atypical outline of a pulmonary nodule has required a differential diagnostic search. The results of imaging RNs in the lung and their dynamics are shown. The given data are discussed.

ревматоидный артритoverlap-синдромсистемная склеродермиявнесуставные проявленияревматоидные узелкиметотрексатлефлуномидсульфасалазинузлы в легкихrheumatoid arthritisoverlap syndromesystemic sclerosisextra-articular manifestationsrheumatoid nodulesmethotrexateleflunomidesulfasalazinepulmonary nodulesReferencesTuresson C, O'Fallon WM, Crowson CS, et al. Extraarticular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years. Ann Rheum Dis. 2003;62(8):722-7. doi: 10.1136/ard.62.8.722Turesson C, O'Fallon WM, Crowson CS, et al. Extraarticular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years. Ann Rheum Dis. 2003;62(8):722-7. doi: 10.1136/ard.62.8.722Carmona L, Gonzalez-Alvaro I, Balsa A, et al. Rheumatoid arthritis in Spain: occurrence of extra-articular manifestations and estimates of disease severity. Ann Rheum Dis. 2003;62(9):897-90. doi: 10.1136/ard.62.9.897Carmona L, Gonzalez-Alvaro I, Balsa A, et al. Rheumatoid arthritis in Spain: occurrence of extra-articular manifestations and estimates of disease severity. Ann Rheum Dis. 2003;62(9):897-90. doi: 10.1136/ard.62.9.897Lake FPS. Rheumatoid arthritis and lung disease: from mechanisms to a practical approach. Semin Resp Crit Care Med. 2014;35:222-38. doi: 10.1055/s-0034-1371542Lake FPS. Rheumatoid arthritis and lung disease: from mechanisms to a practical approach. Semin Resp Crit Care Med. 2014;35:222-38. doi: 10.1055/s-0034-1371542Nannini C, Ryu JH, Matteson EL. Lung disease in rheumatoid arthritis. Curr Opin Rheumatol. 2008;20(3):340-6. doi: 10.1097/BOR.0b013e3282f798edNannini C, Ryu JH, Matteson EL. Lung disease in rheumatoid arthritis. Curr Opin Rheumatol. 2008;20(3):340-6. doi: 10.1097/BOR.0b013e3282f798edTuresson C, O'Fallon WM, Crowson CS, et al. Occurrence of extraarticular disease manifestations is associated with excess mortality in a community based cohort of patients with rheumatoid arthritis. J Rheumatol. 2002;29(1):62-7.Turesson C, O'Fallon WM, Crowson CS, et al. Occurrence of extraarticular disease manifestations is associated with excess mortality in a community based cohort of patients with rheumatoid arthritis. J Rheumatol. 2002;29(1):62-7.Gabriel SE, Crowson CS, Kremers HM, et al. Survival in rheumatoid arthritis: a population-based analysis of trends over 40 years. Arthritis Rheum. 2003;48(1):54-8. doi: 10.1002/art.10705Gabriel SE, Crowson CS, Kremers HM, et al. Survival in rheumatoid arthritis: a population-based analysis of trends over 40 years. Arthritis Rheum. 2003;48(1):54-8. doi: 10.1002/art.10705Turesson C, McClelland RL, Christianson TJ, et al. Multiple extra-articular manifestations are associated with poor survival in patients with rheumatoid arthritis. Ann Rheum Dis. 2006;65(11):1533-4. doi: 10.1136/ard.2006.052803Turesson C, McClelland RL, Christianson TJ, et al. Multiple extra-articular manifestations are associated with poor survival in patients with rheumatoid arthritis. Ann Rheum Dis. 2006;65(11):1533-4. doi: 10.1136/ard.2006.052803Myasoedova E, Crowson CS, Turesson C, et al. Incidence of extraarticular rheumatoid arthritis in Olmsted County, Minnesota, in 1995–2007 versus 1985–94: a population-based study. J Rheumatol. 2011;38(6):983-9. doi: 10.3899/jrheum.101133Myasoedova E, Crowson CS, Turesson C, et al. Incidence of extraarticular rheumatoid arthritis in Olmsted County, Minnesota, in 1995–2007 versus 1985–94: a population-based study. J Rheumatol. 2011;38(6):983-9. doi: 10.3899/jrheum.101133Насонов ЕЛ, Гордеев АВ, Галушко ЕА. Ревматические забо- левания и мультиморбидность. Терапевтический архив. 2015;87(5):4-9 [Nasonov EL, Gordeev AV, Galushko EA. Rheumatic diseases and multimorbidity. Terapevticheskii Arkhiv. 2015;87(5):4-9 (In Russ.)].Насонов ЕЛ, Гордеев АВ, Галушко ЕА. Ревматические забо- левания и мультиморбидность. Терапевтический архив. 2015;87(5):4-9 [Nasonov EL, Gordeev AV, Galushko EA. Rheumatic diseases and multimorbidity. Terapevticheskii Arkhiv. 2015;87(5):4-9 (In Russ.)].Gonzalez-Lopez L, Rocha-Munoz AD, Ponce-Guarneros M, et al. Anticyclic citrullinated peptide (anti-CCP) and antimutated citrullinated vimentin (anti-MCV)-relation with extra-articular manifestations in rheumatoid arthritis. J Immunol Res. 2014;2014:536050. doi: 10.1155/2014/536050Gonzalez-Lopez L, Rocha-Munoz AD, Ponce-Guarneros M, et al. Anticyclic citrullinated peptide (anti-CCP) and antimutated citrullinated vimentin (anti-MCV)-relation with extra-articular manifestations in rheumatoid arthritis. J Immunol Res. 2014;2014:536050. doi: 10.1155/2014/536050Chandrashekara S, Shobha V, Dharmanand BG, et al. Reduced incidence of extra-articular manifestations of RA through effective disease control: Karnataka Rheumatoid Arthritis Comorbidity (KRAC) study. Int J Rheum Dis. 2016 Dec 10. doi: 10.1111/1756-185X.12957 [Epub ahead of print].Chandrashekara S, Shobha V, Dharmanand BG, et al. Reduced incidence of extra-articular manifestations of RA through effective disease control: Karnataka Rheumatoid Arthritis Comorbidity (KRAC) study. Int J Rheum Dis. 2016 Dec 10. doi: 10.1111/1756-185X.12957 [Epub ahead of print].Ziemer M, Mü ller A-K, Hein G, et al. Incidence and classifcation of cutaneous manifestations in rheumatoid arthritis © 2016 Deutsche Dermatologische Gesellschaft (DDG).Ziemer M, Mü ller A-K, Hein G, et al. Incidence and classifcation of cutaneous manifestations in rheumatoid arthritis © 2016 Deutsche Dermatologische Gesellschaft (DDG).Massey H, Darby M, Edey A. Thoracic complications of rheumatoid disease. Clin Radiol. 2013;68(3):293-301. doi: 10.1016/j.crad.2012.07.007Massey H, Darby M, Edey A. Thoracic complications of rheumatoid disease. Clin Radiol. 2013;68(3):293-301. doi: 10.1016/j.crad.2012.07.007Capobianco J, Grimberg A, Thompson BM, et al. Thoracic manifestations of collagen vascular diseases. Radiogr Rev Publ Radiol Soc North Am Inc. 2012;32:33-50. doi: 10.1148/rg.321105058Capobianco J, Grimberg A, Thompson BM, et al. Thoracic manifestations of collagen vascular diseases. Radiogr Rev Publ Radiol Soc North Am Inc. 2012;32:33-50. doi: 10.1148/rg.321105058Ozkaya S, Bilgin S, Hamsici S, Findik S. The pulmonary radiologic findings of rheumatoid arthritis. Respir Med CME. 2011;4(4):187-92. doi: 10.1016/j.rmedc.2011.03.003Ozkaya S, Bilgin S, Hamsici S, Findik S. The pulmonary radiologic findings of rheumatoid arthritis. Respir Med CME. 2011;4(4):187-92. doi: 10.1016/j.rmedc.2011.03.003Yousem SA, Colby TV, Carrington CB. Lung biopsy in rheumatoid arthritis. Am Rev Respir Dis. 1985;131:770-7.Yousem SA, Colby TV, Carrington CB. Lung biopsy in rheumatoid arthritis. Am Rev Respir Dis. 1985;131:770-7.Franquet T. High-resolution CT of lung disease related to collagen vascular disease. Radiol Clin North Am. 2001;39(6):1171-87. doi: 10.1016/S0033-8389(05)70337-7Franquet T. High-resolution CT of lung disease related to collagen vascular disease. Radiol Clin North Am. 2001;39(6):1171-87. doi: 10.1016/S0033-8389(05)70337-7Mori S, Cho I, Koga Y, Sugimoto M. Comparison of pulmonary abnormalities on high-resolution computed tomography in patients with early versus longstanding rheumatoid arthritis. J Rheumatol. 2008;35(8):1513-2.Mori S, Cho I, Koga Y, Sugimoto M. Comparison of pulmonary abnormalities on high-resolution computed tomography in patients with early versus longstanding rheumatoid arthritis. J Rheumatol. 2008;35(8):1513-2.Yunt ZX, Solomon JJ. Lung Disease in Rheumatoid Arthritis. Rheum Dis Clin North Am. 2015 May;41(2):225-36. doi: 10.1016/j.rdc.2014.12.004Yunt ZX, Solomon JJ. Lung Disease in Rheumatoid Arthritis. Rheum Dis Clin North Am. 2015 May;41(2):225-36. doi: 10.1016/j.rdc.2014.12.004King TE Jr, Kim EJ, Kinder BW. Connective tissue diseases. In: Schwarz MI, King TE Jr, eds. Interstitial lung disease. 5th ed. Shelton, Conn: People's Medical Publishing House USA; 2011. 689 p.King TE Jr, Kim EJ, Kinder BW. Connective tissue diseases. In: Schwarz MI, King TE Jr, eds. Interstitial lung disease. 5th ed. Shelton, Conn: People's Medical Publishing House USA; 2011. 689 p.Schreiber J, Koschel D, Kekow J, et al. Rheumatoid pneumoconiosis (Caplan's syndrome). Eur J Intern Med. 2010;21:168-72. doi: 10.1016/j.ejim.2010.02.004Schreiber J, Koschel D, Kekow J, et al. Rheumatoid pneumoconiosis (Caplan's syndrome). Eur J Intern Med. 2010;21:168-72. doi: 10.1016/j.ejim.2010.02.004Галушко ЕА, Беленький ДА, Александрова ЕН, Кашникова ЛН. Роль гепсидина в развитии анемии у больных ревматоидным артритом. Научно-практическая ревматология. 2012;52(3):19-24 [Galushko EA, Belenky DA, Aleksandrova EN, Kashnikova LN. Role of hepcidin in the development of anemia in patients with rheumatoid arthritis. Nauchno- Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2012;50(3):19-24 (In Russ.)]. doi: 10.14412/1995-4484-2012-704Галушко ЕА, Беленький ДА, Александрова ЕН, Кашникова ЛН. Роль гепсидина в развитии анемии у больных ревматоидным артритом. Научно-практическая ревматология. 2012;52(3):19-24 [Galushko EA, Belenky DA, Aleksandrova EN, Kashnikova LN. Role of hepcidin in the development of anemia in patients with rheumatoid arthritis. Nauchno- Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2012;50(3):19-24 (In Russ.)]. doi: 10.14412/1995-4484-2012-704Мазуров ВИ, Богданов АН. Диагностика и лечение поражений легких у больных ревматоидным артритом Научно-практическая ревматология. 2003;41(1):52-6 [Mazurov VI, Bogdanov AN. Diagnosis and treatment of pulmonary lesion in patients with rheumatoid arthritis. Nauchno-Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2003;41(1):52-6 (In Russ.)]. doi: 10.14412/1995-4484-2003-1136Мазуров ВИ, Богданов АН. Диагностика и лечение поражений легких у больных ревматоидным артритом Научно-практическая ревматология. 2003;41(1):52-6 [Mazurov VI, Bogdanov AN. Diagnosis and treatment of pulmonary lesion in patients with rheumatoid arthritis. Nauchno-Prakticheskaya Revmatologiya = Rheumatology Science and Practice. 2003;41(1):52-6 (In Russ.)]. doi: 10.14412/1995-4484-2003-1136Kim SH, Yoo WH. Recurrent pneumothorax associated with pulmonary nodules after leflunomide therapy in rheumatoid arthritis: A case report and review of the literature. Rheumatol Int. 2011;31:919-22. doi: 10.1007/s00296-009-1240-9Kim SH, Yoo WH. Recurrent pneumothorax associated with pulmonary nodules after leflunomide therapy in rheumatoid arthritis: A case report and review of the literature. Rheumatol Int. 2011;31:919-22. doi: 10.1007/s00296-009-1240-9Edwards JCW, Wilkinson LS, Pitsillides AA. Palisading cells of rheumatoid nodules: comparison with synovial intimal cells. Ann Rheum Dis. 1993;52:801-5. doi: 10.1136/ard.52.11.801Edwards JCW, Wilkinson LS, Pitsillides AA. Palisading cells of rheumatoid nodules: comparison with synovial intimal cells. Ann Rheum Dis. 1993;52:801-5. doi: 10.1136/ard.52.11.801Rosenberg EF. The pathology of rheumatoid arthritis In Arthritis and allied conditions. In: Hollander JL, editor. A textbook of rheumatology. Part 2. Boland EW, editor. The study of rheumatoid arthritis. Philadelphia; 1960. P. 179-94.Rosenberg EF. The pathology of rheumatoid arthritis In Arthritis and allied conditions. In: Hollander JL, editor. A textbook of rheumatology. Part 2. Boland EW, editor. The study of rheumatoid arthritis. Philadelphia; 1960. P. 179-94.Baeten D, De Keyser F, Veys EM, et al. Tumour necrosis factor a independent disease mechanisms in rheumatoid arthritis: a histopathological study on the effect of infliximab on rheumatoid nodules. Ann Rheum Dis. 2004;63:489-93. doi: 10.1136/ard.2003.012302Baeten D, De Keyser F, Veys EM, et al. Tumour necrosis factor a independent disease mechanisms in rheumatoid arthritis: a histopathological study on the effect of infliximab on rheumatoid nodules. Ann Rheum Dis. 2004;63:489-93. doi: 10.1136/ard.2003.012302Douglas KM, Ladoyanni E, Treharne GJ, et al. Cutaneous abnormalities in rheumatoid arthritis compared with noninflammatory rheumatic conditions. Ann Rheum Dis. 2006;65(10):1341-5. doi: 10.1136/ard.2005.048934Douglas KM, Ladoyanni E, Treharne GJ, et al. Cutaneous abnormalities in rheumatoid arthritis compared with noninflammatory rheumatic conditions. Ann Rheum Dis. 2006;65(10):1341-5. doi: 10.1136/ard.2005.048934Talotta R, Atzeni F, Batticciotto A, et al. Accelerated subcutaneous nodulosis in patients with rheumatoid arthritis treated with tocilizumab: a case series. J Med Case Rep. 2018;12:154. doi: 10.1186/s13256-018-1687-yTalotta R, Atzeni F, Batticciotto A, et al. Accelerated subcutaneous nodulosis in patients with rheumatoid arthritis treated with tocilizumab: a case series. J Med Case Rep. 2018;12:154. doi: 10.1186/s13256-018-1687-ySayah A, English JC, 3rd. Rheumatoid arthritis: a review of the cutaneous manifestations. J Am Acad Dermatol. 2005;53(2):191-209. doi: 10.1016/j.jaad.2004.07.023Sayah A, English JC, 3rd. Rheumatoid arthritis: a review of the cutaneous manifestations. J Am Acad Dermatol. 2005;53(2):191-209. doi: 10.1016/j.jaad.2004.07.023Watson P, Simler N, Screaton N, Lillicrap M. Management of accelerated pulmonary nodulosis following etanercept therapy in a patient with rheumatoid arthritis. Rheumatology (Oxford). 2008;47:928-9. doi: 10.1093/rheumatology/ken102Watson P, Simler N, Screaton N, Lillicrap M. Management of accelerated pulmonary nodulosis following etanercept therapy in a patient with rheumatoid arthritis. Rheumatology (Oxford). 2008;47:928-9. doi: 10.1093/rheumatology/ken102Toussirot E, Berthelot JM, Pertuiset E, et al. Pulmonary nodulosis and aseptic granulomatous lung disease occurring in patients with rheumatoid arthritis receiving tumor necrosis factor-alpha-blocking agent: A case series. J Rheumatol. 2009;36:2421-7. doi: 10.3899/jrheum.090030Toussirot E, Berthelot JM, Pertuiset E, et al. Pulmonary nodulosis and aseptic granulomatous lung disease occurring in patients with rheumatoid arthritis receiving tumor necrosis factor-alpha-blocking agent: A case series. J Rheumatol. 2009;36:2421-7. doi: 10.3899/jrheum.090030

The authors declare that there are no conflicts of interest present.