【原】类风湿关节炎胸部CT表现：空洞结节实变磨玻璃，什么奇葩都有

小小医生孙丹雄 2024-04-02 发布于云南

展开全文

常记溪亭日暮，沉醉不知归路。

公众号：小小医生之有趣的医学

前言

类风湿关节炎，RA，相关的肺部疾病影像学表现，相当奇葩！

识别这些奇葩表现，对鉴别诊断非常重要。

01 胸膜下空洞

一名66岁有重度吸烟史的女性因双侧多发肺结节被转诊。两年前，她被诊断为类风湿性关节炎（RA），并接受了各种治疗RA的药物治疗，如来氟米特或依那西普，所有这些药物的效果都很有限。由于她持续的咳痰和进行性呼吸困难，对她的胸部X线片进行了评估，显示右侧胸腔积液，伴有多个双侧肺结节。

体格检查显示右侧胸膜摩擦音，双手轻微RA改变。所有血清学或细菌学研究，如血液、痰和尿液染色和培养，均为阴性。胸部计算机断层扫描显示双侧肺空洞结节（图A，箭头）。

非诊断性支气管镜检查后，通过电视胸腔镜手术切除左下肺结节（图a，红色箭头），显示内脏胸膜下方有脓肿样牵拉病变。病理学上，结节由纤维蛋白样坏死核心（NC）（图C）和多核巨细胞（图C，蓝色箭头）组成，周围有栅栏状组织细胞（PH）（图C），伴有周围血管炎，所有这些都与RA坏死性肺结节（NPN）的诊断相一致。过碘酸-雪夫染色和抗酸染色均为阴性，没有恶性肿瘤的证据。

神奇

A 66-year-old woman with a heavy smoking history was referred for multiple bilateral lung nodules. Two years ago, she was diagnosed with rheumatoid arthritis (RA) and had been treated with various drugs for RA, such a leflunomide or etanercept, all of which with limited effects. Because of her persistent productive cough and progressive dyspnea, her chest radiograph was evaluated, which showed right pleural effusion with multiple bilateral lung nodules. Physical examination revealed right pleural friction rubs and slight RA change of both hands. All of the serological or bacteriological studies, such as blood, sputum and urine staining and culture, were negative. A computed tomographic scan of the chest revealed bilateral cavitating lung nodules (Figure A, arrows). After nondiagnostic bronchoscopy, a left lower lung nodule (Figure A, red arrow) was excised by the video-assisted thoracoscopic surgery, which showed the abscess-like, tense lesion just beneath the visceral pleura (Figure B, white arrow). Pathologically, the nodule consists of fibrinoid necrotic core (NC) (Figure C) surrounded by palisading histiocytes (PH) (Figure C) and multinucleated giant cells (Figure C, blue arrow heads) with peripheral vasculitis, all of which were compatible with the diagnosis of necrobiotic pulmonary nodule (NPN) of RA. The periodic acid-schiff staining and acid-fast staining were both negative, and there was no evidence of malignancy.

Yanagisawa, S., Inoue, C., & Ichinose, M. (2017). Necrobiotic Pulmonary Nodules of Rheumatoid Arthritis. The American journal of the medical sciences, 354(3), 329. https:///10.1016/j.amjms.2017.02.007

类风湿肺结节为什么胸膜下分布为主，我猜测是因为类风湿本来就喜欢欺负外周，比如手。到了肺部还是欺负外周。

02 类风湿空洞

你看看嘛，类风湿就喜欢欺负外周。老中医曰：湿气犯类风湿！中央部位血液循环丰富，风和日丽的，类风湿不容易发病。外周部位冷冷的，容易被类风湿侵犯。

03 类风湿肺结节很常见？

Aksoy, A., Kocakaya, D., Yalçınkaya, Y., Bozkurtlar, E., Karakurt, S., Eryüksel, E., & İnanç, N. (2022). Outcome of solid and cavitary pulmonary nodules in rheumatoid arthritis patients-case series. Turkish journal of medical sciences, 52(5), 1713–1720. https:///10.55730/1300-0144.5514

偶然间看到一篇文献，很夸张！

Background: Rheumatoid pulmonary nodule can be detected in up to 32% of rheumatoid arthritis (RA) patients and approximately one-third of nodules may cavitate.

高达32%的类风湿性关节炎（RA）患者可以检测到类风湿性肺结节，大约三分之一的结节可能出现空洞。

至少我敢肯定，确诊的不多。

04 生物制剂治疗

45岁的女性患者，诊断为血清阳性类风湿性关节炎，她因病情恶化而住进了我们的风湿病科。患者的疾病活动性评分（DAS 28）为6.9。体格检查显示，肺部听诊变化为右肺中下叶粗糙呼吸声。胸部X光片显示两肺有多个结节密度。进行肺活检进行诊断，发现坏死性肉芽肿，伴有上皮样细胞包围的中心纤维蛋白样坏死。这种组织病理学图片是典型的类风湿结节。最后，患者接受了利妥昔单抗治疗，病情明显好转。

Sargin, G., & Senturk, T. (2015). Multiple pulmonary rheumatoid nodules. Reumatologia, 53(5), 276–278. https:///10.5114/reum.2015.55831

We present a case of 45-year-old female patient with the diagnosis of seropositive rheumatoid arthritis, who was admitted to our rheumatology department with exacerbation of the disease. The patient's disease activity score (DAS 28) was 6.9. Physical examination revealed changes in the lung auscultation as a rough breathing sound at the middle and lower lobe of the right lung. Chest X-ray revealed multiple nodular densities in both lungs. Lung biopsy was performed for the diagnosis and revealed necrotizing granulomas with central fibrinoid necrosis surrounded by epithelioid cells. Such a histopathological picture is typical for rheumatoid nodules. Finally the patient was treated with rituximab, with significant improvement.

05 PET-CT

Saraya T, Tanaka R, Fujiwara M, et al. Fluorodeoxyglucose (FDG) uptake in pulmonary rheumatoid nodules diagnosed by video-assisted thoracic surgery lung biopsy: two case reports and a review of the literature. Mod Rheumatol. 2013;23(2):393-396. doi:10.1007/s10165-012-0664-3

PET-CT有时候不容易区分类风湿肺结节和恶性肿瘤。

一名44岁的女性，早期（最大3.4）和晚期（最大4.4）出现了一个具有强烈标准化摄取值（SUV）的空洞结节，提示恶性肿瘤。然而，在VATS活检后，她被诊断为类风湿结节伴血管炎。

第二个病例是一名74岁的女性，因双侧肺结节入院，一个肺结节表现为强烈的早期（最大2.2）和延迟（最大6.0）SUV，另外一个肺结节为轻度的早期（最多0.6）和推迟（最大0.9）SUV。这两个结节最终分别被证明是没有血管炎的癌症和类风湿性结节。

这些病例表明，炎症过程增强的类风湿性结节，如血管炎，在FDG-PET/CT扫描图像上可能出现恶性假阳性。

Two cases of rheumatoid nodules evaluated by fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and video-assisted thoracic surgery (VATS) biopsy are reported. The first case was that of a 44-year-old woman who presented with a cavitated nodule with intense standardized uptake values (SUVs) both in the early (max 3.4) and delayed (max 4.4) phases, suggesting malignancy. However, after VATS biopsy, she was diagnosed as having a rheumatoid nodule with vasculitis. The second case was that of a 74-year-old woman admitted with bilateral lung nodules, two of which showed intense early (max 2.2) and delayed (max 6.0) phase SUVs, and mild early (max 0.6) and delayed (max 0.9) phase SUVs. These two nodules were finally proven to be a lung cancer and rheumatoid nodule without vasculitis, respectively. These cases show that rheumatoid nodules with an enhanced inflammatory process, such as vasculitis, can appear false-positive for malignancy on FDG-PET/CT scan images.

06 空洞很乱

类风湿肺空洞的表现很乱，极难鉴别。

乱七八糟，奇形怪状，包罗万象，像特殊感染。

像大肠跑到了肺部（右下肺那个鬼）！

Kanıtez, N. A., Çelik, S., Öner, S. Y., Ürer, H. N., Bes, C., & Çetinkaya, E. (2018). Cavitary pulmonary nodules in rheumatoid arthritis; case reports and review of the literature. European journal of rheumatology, 5(1), 65–68. https:///10.5152/eurjrheum.2017.16106

07 血管供养征

肺类风湿结节也会出现类似肿瘤的血管供养征。

治疗前，如下。

治疗后，如下。

She was treated for rheumatoid lung nodulosis with rituximab with which she improved remarkably.

她接受了利妥昔单抗治疗类风湿性肺结节症，病情明显好转。

Sharma, A., Kasetty, A., & Kumar, A. (2021). Rheumatoid lung nodules with "feeding-vessel" sign. Clinical rheumatology, 40(4), 1645–1647. https:///10.1007/s10067-020-05351-6

08 RA相关间质性肺炎

piu

Esposito, A. J., Chu, S. G., Madan, R., Doyle, T. J., & Dellaripa, P. F. (2019). Thoracic Manifestations of Rheumatoid Arthritis. Clinics in chest medicine, 40(3), 545–560. https:///10.1016/j.ccm.2019.05.003

寻常型间质性肺炎。

非特异性间质性肺炎。

隐源性机化性肺炎。

淋巴细胞性间质性肺炎。

类风湿相关小气道疾病。

吸气时，支气管扩张。

呼气时，马赛克灌注。

类风湿胸膜疾病：胸膜增厚，胸腔积液，气胸。

还有类风湿尘肺！

少见病32：类风湿性尘肺， Caplan syndrome

09 学习视频

肺功能入门知识大全