Bronchoscopic Management of Central Airway Obstruction Secondary to Rheumatoid Arthritis

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To the Editor:
Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease. Pulmonary manifestations of RA are a major contributor of morbidity and mortality.1 Although, interstitial lung disease is the most common pulmonary involvement implicated in about 58% of the cases,2 RA is also known to affect both the upper and lower airways. Central airway diseases related to RA are rarely reported. We report a case of RA-associated left mainstem (LMS) obstruction successfully treated with advanced bronchoscopic interventions alone.
A 55-year-old woman with history of RA and pulmonary nodules, being followed-up by serial chest computed tomographic (CT) scans, was referred to our interventional pulmonology service for worsening dyspnea. She reported progressive dyspnea and worsening cough for the past few months. She received multiple courses of antibiotics, oral steroids, and bronchodilators without significant improvement. She was on adalimumab, methotrexate, and naproxen for her RA. Her physical examination revealed decreased breath sounds at the left lower lobe with wheezing in the left and right upper lobes.
Initial CT chest scans revealed extensive consolidative pneumonia involving the lingula and left lower lobe with ipsilateral mediastinal shift. Atherapeutic bronchoscopy through a laryngeal mask airway was performed. The LMS was severely stenotic with a fibrotic scar starting from the proximal end with more narrowing in the mid LMS which was estimated to be 2 mm in diameter (Figs. 1A, B). This stenosis was diagnosed to be RA related on the basis of patient’s long history of rheumatologist managed RA and pathology specimens showing nonspecific inflammation without evidence of malignancy or scar fibrosis. Because of severe stenosis neither therapeutic/pediatric scope nor controlled radial expansion/CRE balloon (Boston Scientific, Natick, MA) size 8-9-10 mm could pass through the mid-left main stenosis. The patient was then intubated using a rigid scope 10 mm outer diameter (OD), which was advanced to the proximal LMS. A Fogarty balloon catheter 4 Fr was used to dilate the stenotic area. A CRE balloon 8-9-10 mm could now be inserted through the stenosis to perform sequential airway dilation up to 8 mm. The LMS stenosis was then dilated using the rigid scope 10 mm OD followed by 12 mm OD. Significant purulent discharge was suctioned from the distal LMS and the distal airways of the left upper and lower lobes were visualized. The flexible bronchoscope was then inserted through the rigid scope and the CRE balloon 8-9-10 mm followed by 10-11-12 mm were used to dilate the LMS. The length of the stenotic airway was now 25 mm. A Dumon studded silicone 12×30 mm stent was deployed in the LMS. Patient later followed with serial CT chest scans performed every 3 to 6 months and frequent interval flexible bronchoscopy for stent inspection (Figs. 1C, D). The stent was removed after 1 year and follow-up CT chest 12 months later showed stable mild stenosis of the LMS bronchus.
Pulmonary manifestations of RA can include pleuritic pain/ pleural effusions, obliterative bronchiolitis, fibrosing alveolitis, rheumatoid nodules, and rheumatoid vasculitis. Pulmonary involvement can occur within 5 years of diagnosis and up to 20% cases can have respiratory symptoms before articular complaints.3,4 RA can affect both upper and lower airways. The upper airway manifestations are commonly found in females with long standing severe RA. Cricoarythenoid joint arthritis is a well-known cause of upper airway symptoms in patients with RA which may necessitate for emergent tracheostomy. Rheumatoid nodules affecting peripheral airways and lung parenchyma and central involvement are very rare. Johnson et al5 reported central endobronchial rheumatoid necrobiotic nodule obstructing left mainstem bronchus 7 years before developing typical RA symptoms.

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