Q&A Medicine>>>>>Pulmonology
Question 56#

A 55-year-old Caucasian man is brought into the Emergency Department by his wife because of increasing shortness of breath. Symptoms developed gradually over the past few months are exacerbated by exertion, and are associated with a chronic dry cough. The patient’s medical history is significant for hypertension and rheumatoid arthritis, and he takes hydrochlorothiazide and daily NSAIDs. He has smoked 2 packs of cigarettes daily for the past 15 years and drinks alcohol moderately. His temperature is 36.7°C, blood pressure is 142/88 mmHg, heart rate is 94 beats per minute, respiratory rate is 24 breaths per minute, and oxygen saturation is 91% on room air. The physical examination is notable for bibasilar dry crackles, a right ventricular heave, clubbing of the digits, and mild pitting edema around the ankles. There is also some tenderness to palpation in the epigastric area. Testing the stool for occult blood is positive.

Which of the following could have prevented the development of this patient’s lung disease?

a. Adequate blood pressure control
b. Smoking cessation
c. Early initiation of disease modifying antirheumatic drugs (DMARDs)
d. Bronchodilator therapy
e. Colonoscopy

Correct Answer is B

Comment:

Smoking cessation. In the setting of rheumatoid arthritis, the symptoms/signs of dyspnea on exertion, chronic dry cough, clubbing, and bibasilar dry crackles are indicative of rheumatoid arthritis-associated interstitial lung disease. This complication typically presents around the age of 50 to 60 and typically affects the lower lungs. Risk factors for developing this complication include male gender, severity of disease (correlates with a high rheumatoid factor level), and smoking. In addition to the presentation, other findings that suggest this diagnosis are a restrictive pattern on pulmonary function tests and reticular or ground glass changes on a CT scan. Smoking cessation is the best preventive measure, and is always a good answer choice for the shelf examination. (C) Early initiation of DMARDs such as methotrexate, azathioprine, rituximab, calcineurin inhibitors, and tumor necrosis factor blockers is a good answer choice since they have been a major improvement in the treatment of patients with rheumatoid arthritis and can slow down disease progression. However, there is less of a correlation between the development of interstitial lung disease and DMARD initiation than other disease features (e.g., joint destruction). Smoking cessation is still the best option for preventing interstitial lung disease associated with rheumatoid arthritis.

(A) Hypertension would not produce the lung findings seen in this patient, and the patient’s current blood pressure is only mildly elevated. The findings of a right ventricular heave and peripheral edema may be signs of pulmonary hypertension and early right heart failure (cor pulmonale) from the patient’s lung disease. (D) The findings on examination are more consistent with interstitial lung disease (dry crackles) than with COPD (wheezes, hyperinflated lungs). (E) The epigastric pain with occult blood in the stool is likely a result of a bleeding peptic ulcer from chronic NSAID use, not colon cancer. Metastatic disease to the lungs from colon cancer would not produce bibasilar dry crackles.