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Dawson et al1 found HRCT evidence of fibrosing alveolitis (FA) in 19% of 150 outpatients with rheumatoid arthritis (RA). The presence of FA did not relate to previously described predisposing factors such as male sex, nodular and/or extra-articular disease, disease duration and severity. Moreover, the authors did not find any relation with respiratory symptoms such as dyspnoea or cough, chest radiographic appearance of FA, or restrictive pattern at pulmonary function tests. The only features significantly associated with FA on the HRCT scan were the presence of bibasal crackles and the reduction in carbon monoxide transfer factor (Tlco). These findings are more difficult to explain, especially considering that FA was defined as an HRCT pattern “typical” of usual interstitial pneumonia according to a more recent classification.2 Other studies had shown a high prevalence of FA, even in recent onset RA.3
We have recently investigated the presence of pulmonary disease in 24 consecutive patients with RA without respiratory symptoms or signs and a normal chest radiograph. In all these patients we performed a chest HRCT scan as well as complete pulmonary function tests (PFTs). Our patients were predominantly women (22/24), of mean age 49.4 years (range 26–72), and 46% of them had a disease duration of less than 2 years. Only 33.3% were current smokers. We found Tlco of <75% in 50% of the patients; two patients had obstructive PFT and one patient restrictive PFT. Pleuropulmonary alterations were detected in 20.8% of the patients on the HRCT scan, but only one patient had an HRCT pattern suggestive of FA according to stringent criteria.2 In all the other patients the alterations observed were mild and non-specific (pleural abnormalities, septal and non-septal lines, micronodules). Our data confirm a rather high prevalence of pleuropulmonary alterations in patients with RA, even in the absence of respiratory symptoms. However, we found evidence of FA much less frequently than Dawson et al.1 This difference may only be partly explained by patient selection: not all our patients had respiratory symptoms and almost half of them had RA of short duration. The newly available diagnostic techniques such as HRCT scanning have increased interest in evaluating patients with connective tissue diseases. However, the clinical relevance of the frequently observed pulmonary alterations in patients with RA has still to be elucidated, as well as the best diagnostic approach to respiratory involvement in this multifaceted disease.
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