New pulmonary nodules in a patient with rheumatoid arthritis.

To cite: Saba R, Ali AM, Kwatra SG, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2012008344 DESCRIPTION A 35-year-old male with a history of rheumatoid arthritis and rheumatoid pulmonary nodules and Graves’ disease was admitted to the hospital due to new onset fever, worsening dyspnoea and cough. Laboratory workup showed leukocytosis, haematuria, elevated erythrocyte sedimentation rate and cytoplasmic antineutrophil cytoplasmic antibodies. CT of the chest showed an increase in the size and number of lung masses (figure 1) compared to imaging performed 2 years prior, and a new airfluid level mass in the apical area of the right lung (figure 2). Bronchoscopy with bronchoalveolar lavage demonstrated mild interstitial pneumonitis, fibrosis and positive cultures for Streptococcus pneumonia. Transbronchial biopsy showed granulomatous vasculitis. The patient improved after receiving a high dose of methylprednisolone, and levofloxacin. He was discharged home on a maintenance prednisone and levofloxacin. The presence of pulmonary nodules with cavitation requires a thorough workup to establish a primary diagnosis. Differential diagnosis includes tuberculosis and other bacterial disease such as nocardiosis, fungal infections such as aspergillosis, granulomatosis with polyangiitis and other autoimmune diseases and malignancy (particularly squamous cell cancer lung cancer). Lung biopsy may be required to establish a definitive diagnosis. Granulomatosis with polyangiitis is the most common autoimmune disorder presenting with cavitary pulmonary lesions.