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Compromiso Pulmonar en ARTRITIS REUMATOIDEA
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Compromiso Pulmonar en ARTRITIS REUMATOIDEA

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Compromiso Pulmonar en ARTRITIS REUMATOIDEA

Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Presentación final rota Reumato UdeC MI

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  • Most Frequent High-resolution Computed Tomography Patterns in Rheumatoid Arthritis Associated Interstitial Lung Disease (ILD)
  • Generalmente subclínica Autopsias 40-70% Pleuresía 5-20% Derrame Rx 5%
  • Unique pleural fluid findings in RA. Triad of comet cells, giant cells and background of granular material. Seen in as many as 80% of pleural specimens and are considered unique to RA. These findings are the result of the exfoliation of pleural components from regions of granulomatous pleuritis. The RA cell (or ragocyte) is a leukocyte with small cytoplasmic lipid inclusions containing RF. These may also be seen in TB.
  • Caplan A. Certain radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis. Torax 1953;8:29-37.
  • Caplan A. Certain radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis. Torax 1953;8:29-37.
  • Caplan A. Certain radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis. Torax 1953;8:29-37.
  • Caplan A. Certain radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis. Torax 1953;8:29-37.
  • Caplan A. Certain radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis. Torax 1953;8:29-37.
  • Caplan A. Certain radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis. Torax 1953;8:29-37.
  • Comparison of the Kaplan-Meier survival curves between the subject groups and the UIP pattern associated with rheumatoid arthritis (RA-UIP). CVD-NSIP = nonspecific interstitial pneumonia associated with collagen vascular diseases; I-NSIP = idiopathic nonspecific interstitial pneumonia; IPF/UIP = idiopathic pulmonary fibrosis/usual interstitial pneumonia; non–RA-UIP = usual interstitial pneumonia in the patients with non–rheumatoid arthritis–collagen vascular diseases. The statistical significances between groups were as follows: RA-UIP versus non–RA-UIP, p = 0.015; RA-UIP versus CVD-NSIP, p = 0.043; RA-UIP versus I-NSIP, not significant; RA-UIP versus IPF/UIP, not significant. Reprinted by permission from Reference Park JH, Kim DS, Park IN, Jang SJ, Kitaichi M, Nicholson AG, Colby TV. Prognosis of fibrotic interstitial pneumonia: idiopathic versus collagen vascular disease-related subtypes. Am J Respir Crit Care Med 2007;175:705–711
  • Grupo 1: EPD + tos seca + disnea Grupo 2: Alteraciones no EPD Grupo 3: Sin EPD
  • Grupo 1: EPD + tos seca + disnea Grupo 2: Alteraciones no EPD Grupo 3: Sin EPD
  • Table 2. Most Frequent Pulmonary Abnormalities Detected with High-resolution Computed Tomography Patterns in Rheumatoid Arthritis
  • Grupo 1: EPD + tos seca + disnea Grupo 2: Alteraciones no EPD Grupo 3: Sin EPD
  • Most Frequent High-resolution Computed Tomography Patterns in Rheumatoid Arthritis Associated Interstitial Lung Disease (ILD)
  • Most Frequent High-resolution Computed Tomography Patterns in Rheumatoid Arthritis Associated Interstitial Lung Disease (ILD)
  • Most Frequent High-resolution Computed Tomography Patterns in Rheumatoid Arthritis Associated Interstitial Lung Disease (ILD)
  • 1. Zisman D A, McCune W J, Tino G, Lynch J P I. Drug-induced pneumonitis: the role of methotrexate. Sarcoidosis Vasc Diffuse Lung Dis 2001; 18: 243-2522. Dai M S, Ho C L, Chen Y C, Kao W Y, Chao T Y. Acute respiratory distress syndrome following intrathecal methotrexate administration: a case report and review of literature. Annals of Hematology 2000; 79: 696-6993. Imokawa S, Colby T V, Leslie K O, Helmers R A. Methotrexate pneumonitis: review of the literature and histopathological findings in nine patients. Eur Respir J 2000; 15: 373-3814. McKenna K E, Burrows D. Pulmonary toxicity in a patient with psoriasis receiving methotrexate therapy. Clin Exp Dermatol 2000; 25: 24-275. Sing A, Leitritz L, Roggenkamp A, Kolb H J, Szabados A, Fingerle V, Autenrieth I B, Heesemann J. Pulmonary toxoplasmosis in bone marrow transplant recipients: Report of two cases and review. Clin Infect Dis 1999; 29: 429-433 6. Suwa A, Hirakata M, Satoh S, Mimori T, Utsumi K, Inada S. Rheumatoid arthritis associated with methotrexate-induced pneumonitis: Improvement with i.v. cyclophosphamide therapy. Clin Exp Rheumatol 1999; 17: 355-3587. Yoshida S, Onuma K, Akahori K, Sakamoto H, Yamawaki Y, Shoji T, Nakagawa H, Hasegawa H, Amayasu H. Elevated levels of IL-8 in interstitial pneumonia induced by low-dose methotrexate. Journal of Allergy and Clinical Immunology 1999; 103: 952-9548. Zingg K, Grossenbacher M, Conen D, Truninger K. Methotrexat-Pneumonitis. Schweizerische Rundschau Medizinische Praxis 1999; 88: 573-5789. Aaron S D, Dales R E, Pham B. Management of steroid-dependent asthma with methotrexate: a meta-analysis of randomized clinical trials. Respir Med 1998; 92: 1059-106510. Bartram S A. Experience with methotrexate-associated pneumonitis in northeastern England: comment on the article by Kremer et al. Arthr Rheum 1998; 41: 1327-132811. Camiciottoli G, Trapani S, Castellani W, Ginanni R, Ermini M, Falcini F. Effect on lung function of methotrexate and non-steroid anti-inflammatory drugs in children with juvenile rheumatoid arthritis. Rheumatol Int 1998; 18: 11-1612. Cron R Q, Sherry D D, Wallace C A. Methotrexate-induced hypersensitivity pneumonitis in a child with juvenile rheumatoid arthritis. J Pediatr 1998; 132: 901-90213. Hassanein T, Monson P, Chatfield E, DeGuzman L, El Mola T. Hign ANA levels do not preclude interferon therapy in patients with chronic hepatitis C infection. American Journal of Gastroenterology 1998; 93: 167614. Kremer J M. Experience with methotrexate-associated pneumonitis in northeastern England. Arthr Rheum 1998; 41: 1328-132815. Mateo I, Canete C, Nolla J M, Fiter J, Rodriguez Sanchon B, Romero P. Evolution of pulmonary function in rheumatoid arthritis patients taking methotrexate. Br J Rheumatol 1998; 37 (Suppl 1): 11816. Weinblatt M E, Maier A L, Fraser P A, Coblyn J S. Long-term prospective study of methotrexate in the treatment of rheumatoid arthritis: conclusion after 132 months of therapy. J Rheumatol 1998; 25: 238-24217. Clearkin R, Corris P A, Thomas S H L. Methotrexate pneumonitis in a patient with rheumatoid arthritis. Postgrad Med J 1997; 73: 603-60418. Horrigan T J, Fanning J, Marcotte M P. Methotrexate pneumonitis after systemic treatment for ectopic pregnancy. Am J Obstet Gynecol 1997; 176: 714-71519. Ohosone Y, Okano Y, Kameda H, Fujii T, Hama N, Hirakata M, Mimori T, Akizuki M, Ikeda Y. Clinical characteristics of patients with rheumatoid arthritis and methotrexate-induced pneumonitis. J Rheumatol 1997; 24: 2299-230320. Salaffi F, Manganelli P, Carotti M, Subiaco S, Lamanna G, Cervini C. Methotrexate-induced pneumonitis in patients with rheumatoid arthritis and psoriatic arthritis: report of five cases and review of the literature. Clin Rheumatol 1997; 16: 296-30421. Schnabel A, Richter C, Bauerfeind S, Gross W L. Bronchoalveolar lavage cell profile in methotrexate induced pneumonitis. Thorax 1997; 52: 377-37922. Thomas E, Mazyad H, Olive P, Blotman F. Cytomegalovirus-induced pneumonia in a rheumatoid arthritis patient treated with low dose methotrexate. Clin Exp Rheumatol 1997; 15: 583-58423. Alkins S A, Byrd J C, Morgan S K, Ward F T, Weiss R B. Anaphylactoid reactions to methotrexate. Cancer 1996; 77: 2123-212624. Schnabel A, Dalhoff K, Bauerfeind S, Barth J, Gross W L. Sustained cough in methotrexate therapy for rheumatoid arthritis. Clin Rheumatol 1996; 15: 277-28225. Israel C M. Severe pneumonitis as complication of low-dose methotrexate therapy in psoriasis-related polyarthritis. Reply. Dtsch Med Wschr 1995; 120: 1224-122526. van der Veen M J, Dekker J J, Dinant H J, Van Soesbergen R M, Bijlsma J W J. Fatal pulmonary fibrosis complicating low dose methotrexate therapy for rheumatoid arthritis. J Rheumatol 1995; 22: 1766-176827. 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  • 1. Zisman D A, McCune W J, Tino G, Lynch J P I. Drug-induced pneumonitis: the role of methotrexate. Sarcoidosis Vasc Diffuse Lung Dis 2001; 18: 243-2522. Dai M S, Ho C L, Chen Y C, Kao W Y, Chao T Y. Acute respiratory distress syndrome following intrathecal methotrexate administration: a case report and review of literature. Annals of Hematology 2000; 79: 696-6993. Imokawa S, Colby T V, Leslie K O, Helmers R A. Methotrexate pneumonitis: review of the literature and histopathological findings in nine patients. Eur Respir J 2000; 15: 373-3814. McKenna K E, Burrows D. Pulmonary toxicity in a patient with psoriasis receiving methotrexate therapy. Clin Exp Dermatol 2000; 25: 24-275. Sing A, Leitritz L, Roggenkamp A, Kolb H J, Szabados A, Fingerle V, Autenrieth I B, Heesemann J. Pulmonary toxoplasmosis in bone marrow transplant recipients: Report of two cases and review. Clin Infect Dis 1999; 29: 429-433 6. Suwa A, Hirakata M, Satoh S, Mimori T, Utsumi K, Inada S. Rheumatoid arthritis associated with methotrexate-induced pneumonitis: Improvement with i.v. cyclophosphamide therapy. Clin Exp Rheumatol 1999; 17: 355-3587. Yoshida S, Onuma K, Akahori K, Sakamoto H, Yamawaki Y, Shoji T, Nakagawa H, Hasegawa H, Amayasu H. Elevated levels of IL-8 in interstitial pneumonia induced by low-dose methotrexate. Journal of Allergy and Clinical Immunology 1999; 103: 952-9548. Zingg K, Grossenbacher M, Conen D, Truninger K. Methotrexat-Pneumonitis. Schweizerische Rundschau Medizinische Praxis 1999; 88: 573-5789. Aaron S D, Dales R E, Pham B. Management of steroid-dependent asthma with methotrexate: a meta-analysis of randomized clinical trials. Respir Med 1998; 92: 1059-106510. Bartram S A. Experience with methotrexate-associated pneumonitis in northeastern England: comment on the article by Kremer et al. Arthr Rheum 1998; 41: 1327-132811. Camiciottoli G, Trapani S, Castellani W, Ginanni R, Ermini M, Falcini F. Effect on lung function of methotrexate and non-steroid anti-inflammatory drugs in children with juvenile rheumatoid arthritis. Rheumatol Int 1998; 18: 11-1612. Cron R Q, Sherry D D, Wallace C A. Methotrexate-induced hypersensitivity pneumonitis in a child with juvenile rheumatoid arthritis. J Pediatr 1998; 132: 901-90213. Hassanein T, Monson P, Chatfield E, DeGuzman L, El Mola T. Hign ANA levels do not preclude interferon therapy in patients with chronic hepatitis C infection. American Journal of Gastroenterology 1998; 93: 167614. Kremer J M. Experience with methotrexate-associated pneumonitis in northeastern England. Arthr Rheum 1998; 41: 1328-132815. Mateo I, Canete C, Nolla J M, Fiter J, Rodriguez Sanchon B, Romero P. Evolution of pulmonary function in rheumatoid arthritis patients taking methotrexate. Br J Rheumatol 1998; 37 (Suppl 1): 11816. Weinblatt M E, Maier A L, Fraser P A, Coblyn J S. Long-term prospective study of methotrexate in the treatment of rheumatoid arthritis: conclusion after 132 months of therapy. J Rheumatol 1998; 25: 238-24217. Clearkin R, Corris P A, Thomas S H L. Methotrexate pneumonitis in a patient with rheumatoid arthritis. Postgrad Med J 1997; 73: 603-60418. Horrigan T J, Fanning J, Marcotte M P. Methotrexate pneumonitis after systemic treatment for ectopic pregnancy. Am J Obstet Gynecol 1997; 176: 714-71519. Ohosone Y, Okano Y, Kameda H, Fujii T, Hama N, Hirakata M, Mimori T, Akizuki M, Ikeda Y. Clinical characteristics of patients with rheumatoid arthritis and methotrexate-induced pneumonitis. J Rheumatol 1997; 24: 2299-230320. Salaffi F, Manganelli P, Carotti M, Subiaco S, Lamanna G, Cervini C. Methotrexate-induced pneumonitis in patients with rheumatoid arthritis and psoriatic arthritis: report of five cases and review of the literature. Clin Rheumatol 1997; 16: 296-30421. Schnabel A, Richter C, Bauerfeind S, Gross W L. Bronchoalveolar lavage cell profile in methotrexate induced pneumonitis. Thorax 1997; 52: 377-37922. Thomas E, Mazyad H, Olive P, Blotman F. Cytomegalovirus-induced pneumonia in a rheumatoid arthritis patient treated with low dose methotrexate. Clin Exp Rheumatol 1997; 15: 583-58423. Alkins S A, Byrd J C, Morgan S K, Ward F T, Weiss R B. Anaphylactoid reactions to methotrexate. Cancer 1996; 77: 2123-212624. Schnabel A, Dalhoff K, Bauerfeind S, Barth J, Gross W L. Sustained cough in methotrexate therapy for rheumatoid arthritis. Clin Rheumatol 1996; 15: 277-28225. Israel C M. Severe pneumonitis as complication of low-dose methotrexate therapy in psoriasis-related polyarthritis. Reply. Dtsch Med Wschr 1995; 120: 1224-122526. van der Veen M J, Dekker J J, Dinant H J, Van Soesbergen R M, Bijlsma J W J. Fatal pulmonary fibrosis complicating low dose methotrexate therapy for rheumatoid arthritis. J Rheumatol 1995; 22: 1766-176827. 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Compromiso Pulmonar en ARTRITIS REUMATOIDEA Compromiso Pulmonar en ARTRITIS REUMATOIDEA Presentation Transcript

  • COMPROMISO PULMONAR EN ARTRITIS REUMATOIDEA Miércoles 23 de Junio 2010 Julián Vega Adauy , Residente Medicina Interna Universidad de Concepción PRESENTACION FINAL ROTACION REUMATOLOGIA
  •  
  • OBJETIVOS DE LA PRESENTACIÓN
    • Conocer las diversas manifestaciones pulmonares de las enfermedades reumatológicas
    • Comprender el espectro de enfermedades pulmonares difusas (EPD)
    • Comprender el compromiso pulmonares de la AR (CP-AR)
    • Conocer estudio y evaluación del paciente CP-AR
    • Conocer los tratamientos disponibles
  • ÍNDICE DE PRESENTACIÓN
    • Introducción,
    • Manifestaciones pulmonares CTD
    • Manifestaciones pulmonares de la AR
      • Compromiso pleural
      • Nódulos en AR
      • EPD
      • HAP
      • Secundario a Rp
    • Enfermedad pulmonar difusa (EPD)
  • ÍNDICE DE PRESENTACIÓN
    • Introducción,
    • Manifestaciones pulmonares CTD
    • Manifestaciones pulmonares de la AR
    • Enfermedad pulmonar difusa (EPD)
    • Las enfermedades colágeno-vasculares o del tejido conectivo (CVD o CTD) son un grupo heterogéneo de desordenes autoinmunes
        • LES, AR, ESP, SD, DM, PM, SA, SS, EMTC
    • Muchas de ellas afectan al pulmón de manera directa o indirectamente mediante su tratamiento
    • Diferentes componentes del sistema respiratorio pueden verse afectados
      • (vía aérea de diverso calibre, vasculatura, parénquima, pleura, musculatura respiratoria)
    • La Enfermedad pulmonar difusa (EPD - ILD) es la complicación más frecuente de las CTD, sin embargo existen múltiples formas de compromiso pleuro-pulmonar
    eMedicine. A. Ali 2008 — INTRODUCCIÓN
    • El término de Enfermedad Pulmonar Difusa corresponde a la afección que compromete al componente intersticial y alveolar principalmente
    • La literatura anglosajona se refiere a las EPD como Enfermedades Intersticiales del pulmón (ILD)
    • Pero también se puede comprometer la vasculatura y la pequeña via aérea.
      • Por tanto el término Enfermedad intersticial seria menos adecuado que el de EPD
    • Corresponden hasta el 15% de la práctica Neumológica
    K Leslie. Pulmonary Pathology of the Rheumatic Diseases. Semin Respir Crit Care Med 2007 — INTRO, ENFERMEDAD PULMONAR DIFUSA
    • En cuanto a la afección de la vasculatura puede manifestarse como:
      • Hemorragia Alveolar
      • Hipertensión Arterial Pulmonar (HAP)
    • 2. La Hipertensión Arterial Pulmonar (HAP) en las CTD puede estar:
      • En el contexto de una EPD (secundaria)
      • Aislada (HAP Asociada a CTD)
      • El contexto clínico-histológico de la HAP puede ser indistinguible
    M Hoeper. Eur Respir J. 2002 — INTRODUCCIÓN
  • HIPERTENSIÓN PULMONAR 2ria EPD PRIMARIA (ASOCIADA) ETE crónica ENFERMEDAD TEJ CONECTIVO K. Fagan. Progress in Cardiovascular Diseases 2002
  • E. Kim. Radiographics 2002 COMPROMISO PULMONAR Y CTD
    • Las cinco enfermedades reumatológicas asociadas con mayor frecuencia a compromiso pleuro-pulmonar son (1)
    • K Leslie. Pulmonary Pathology of the Rheumatic Diseases. Semin Respir Crit Care Med 2007
    • Felizardo M, Rev Port Pneumol. 2005
    COMPROMISO PULMONAR Y CTD 30% EPD En GLOBO CTD (2) FRECUENCIA ENFERMEDAD CR, EPD Sd. Sjögren (SS) CR, EPD Polimiositis-Dermatomiositis (PM-DM) 60% Esclerosis sistémica progresiva (ESP) 50-70% Lupus Eritematoso Sistémico (LES) 60%, 20% Pleuresía, 10-60% EPD Artritis Reumatoidea (AR)
  • — INTRODUCCION K Brown. Proceedings ATS. 2007
  • — INTRODUCCION K Brown. Proceedings ATS. 2007 IMPORTANCIA DEL COMPROMISO EXT-ART Claro impacto en mortalidad
    • SMR, standardized mortality ratio:
      • 1.6 [1.5 - 1.8] Meune, Rheumatology. 2009
      • 2.6 [1.98 - 3.08] Wolfe F, Arthritis Rheum. 1994
    • Manifestaciones extra-articulares como causas de muerte en AR
    • Causas Cardiovasculares 40-60%
    • Respiratorias 10-20%
    • Infecciosos, Renales, Neoplasias 5-7% c/u
    EXCESO DE MORTALIDAD EN ARTRITIS REUMATOIDEA
  • ÍNDICE DE PRESENTACIÓN
    • Introducción, EPD, HTP
    • Manifestaciones pulmonares CTD
    • Manifestaciones pulmonares de la AR
    • Enfermedad pulmonar difusa (EPD)
  • — ANTECEDENTES HISTÓRICOS DEL PULMÓN REUMATOIDEO Ellman, BMJ. 1948 Relación entre casos de AR con compromiso pulmonar difuso Caplan, thorax. 1953 Neumoconiosis asociada a AR en trabajadores del carbón Patrón nodular particular, distinto al de la llamada Fibrosis pulmonar masiva 1954, fueron reportados Nódulos pulmonares en ausencia de Neumoconiosis Sinclair. Q J Med. 1955 Alta frecuencia de compromiso pleural en AR Cudkowicz Br J Dis Chest 1961 Describió primeras biopsias y estudios de Fx pulmonar en AR + Compromiso pulmonar
  • PULMÓN REUMATOIDEO
  • Current Opin Rheumatol 2008 COMPROMISO PULMONAR AR
  • Current Opin Rheumatol 2008 COMPROMISO PULMONAR AR Variadas manifestaciones pleuro-pulmonares de la AR
  • UpToDate 18.3. 2010
    • Frente a una paciente con AR y compromiso pulmonar tenemos las siguientes posibilidades, compromiso pulmonar:
    ARTRITIS REUMATOIDEA (AR) COMPROMISO PULMONAR EN AR 5. Síndrome clínico sobrepuesto 4. Condición médica co-existente (Asma, ICC, LCFA) 3. Infección (favorecido por estado inmunosupresión) 2. Asociado al tratamiento de la AR 1. Asociado a AR (Rheumatoid-associated lung disease )
      • Compromiso de vía aérea
    COMPROMISO PULMONAR EN AR
      • HAP en AR
      • EPD en AR
      • Nódulos pulmonares en AR
      • Compromiso pleural
    1. Asociado a AR (Rheumatoid-associated lung disease )
      • Compromiso de vía aérea
    COMPROMISO PULMONAR EN AR
      • HAP en AR
      • EPD en AR
      • Nódulos pulmonares en AR
      • Compromiso pleural
    1. Asociado a AR (Rheumatoid-associated lung disease )
    • Pleuresía con (80%) o sin derrame (20%)
    • CP es generalmente subclínico (1)
    • Más frecuente en hombres con FR elevados, AR activas y de larga data*
    • Hallazgo post-mortem hasta 40-70%
    • Balbir-Gurman A. Semin Arthritis Rheum. 2006
    COMPROMISO PLEURAL (CP) <5% Derrame a Rx 5-20% Pleuresía 40-70% Asintomático (Hallazgo autopsia) FREC CLINICA CP
    • CARACTERISTICAS CLINICAS
    • Molestias más frecuentes son:
      • Tos, dolor pleurítico y disnea
    • Presentarse en conjunto con molestias articulares
      • 25% precederlas
    • Coexistir con una EPD y Nódulos Reumatoideos 30%
    • No tiene muchas particularidades clínicas ni Rx
    • Hallazgo incidental en Rx
    • Uni o bilateral
    • Resolverse sólo, persistir por meses o ser recurrente
    • El estudio del LP tiene ciertas características específicas
    COMPROMISO PLEURAL (CP) UpToDate 18.3. 2010
  • LIQUIDO PLEURAL EN DP x AR
    • Líquido pleural exudado característico, Diferencial de Empiema
    • Glucosa baja (<25-40 mg/dl, <0,5 c/r Plasma)
    • Complemento bajo
    • LDH y Proteínas Altas
    • FR mayor a FR del suero
    • PMN, Ragocitos (RA Cells no es E ni S)
    DERRAME PLEURAL + AR
  •  
  • V Luiza. J. Pneumologia 2003
  • V Luiza. J. Pneumologia 2003
  • Source: Johns Hopkins Arthritis
  •  
  •  
  • TRATAMIENTO DERRAME PLEURAL + AR
    • CONCEPTOS
    • Pleurocentesis en todo derrame, descartar otras etiologías
    • Generalmente no requiere Rp específico, se resuelve espontáneo (1-36M, Promedio 14M).
    • CONTROLAR LA ENFERMEDAD ES CLAVE
  • TRATAMIENTO DERRAME PLEURAL + AR
    • TERAPIAS DISPONIBLES
    • AINEs, Corticoides vo/ip, pleurodesis, decorticación
    • DOLOR: AINEs, Indometacina
    • DERRAME REFRACTARIO
      • Prednisona 10-20mg dia
      • Imposibilidad de Cortis vo: Metilpredni depot 120-160mg ip
    • 3. DERRAME Crónico
      • Pleurodesis y Cx si corresponde es excepcional
      • Compromiso de vía aérea
    COMPROMISO PULMONAR EN AR
      • HAP en AR
      • EPD en AR
      • Nódulos pulmonares en AR
      • Compromiso pleural
    1. Asociado a AR (Rheumatoid-associated lung disease )
  • COMPROMISO NODULAR PULMONAR No Neumocócicos (Necrobióticos) Neumocócicos (Sd. Caplan)
    • Primera descripción corresponde a ANTHONY CAPLAN en 1953
    • Caplan A. Certain radiological appearances in the chest of coal-miners suffering from rheumatoid arthritis. Torax 1953;8:29-37 .
    • Descubrió a la Rx múltiples nódulos bilaterales en mineros del carbón con AR (51 – 14.000)
    • SD. CAPLAN
    • Única manifestación pulmonar privativa de la AR
    • Puede anteceder el compromiso articular de la AR
    • Cada vez menos frecuente, Antes 1-100.000
    • Nódulos redondeados, bien definidos, 0.5 - 2 cm de diámetro (diff TB)
    • Espiro: Patrón Restrictivo + componente obstructivo
    COMPROMISO NODULAR PULMONAR
  • COMPROMISO NODULAR PULMONAR
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  • COMPROMISO NODULAR PULMONAR
  • COMPROMISO NODULAR PULMONAR
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    • NÓDULOS NO NEUMOCÓCICOS
    • Prevalencia de nódulos pulmonares en AR depende del método de estudio
      • Rx de rutina <0.5-1%, TAC-AR 4-10%, Biopsias 30%
      • Se ha relacionado con uso de anti-TNF y leflunomida
      • Más frecuente en Hombres
    • Nódulos intrapulmonares mm – 7 cm
    • Asociados a derrame pleural o EPD
    • Raramente sintomáticos: Obstrucción, compresión, cavitación  hemoptisis
    • Histología similar a nódulos de otras localizaciones (sc)
    • Rx. Opacidades periféricas, a veces Bp para diferencial
    COMPROMISO NODULAR PULMONAR
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      • Compromiso de vía aérea
    COMPROMISO PULMONAR EN AR
      • HAP en AR
      • EPD en AR
      • Nódulos pulmonares en AR
      • Compromiso pleural
    1. Asociado a AR (Rheumatoid-associated lung disease )
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    • Una de las primeras asociaciones histopatológicas entre CTD y EPD, fue la serie publicada por Ellman y Ball en 1948.
      • Mediante necropsias encontraron una relación entre la antiguamente llamada Alveolitis Fibrosante y la AR (1)
    • Ellman et al. . BMJ 1948
    — ENFERMEDAD PULMONAR DIFUSA + AR
    • Existen pocos datos sobre su epidemiología.
    • Los datos que se conocen son muy variables.
    • Los cambios en la clasificación impiden conocer con certeza la incidencia y prevalencia de nuevas entidades clínicas.
    • Pero existe acuerdo general que las EPID más frecuentes son:
      • Fibrosis pulmonar idiopática
      • Alveolitis alérgica extrínseca
      • Enfermedad asociada a Mesenquimopatías (CTD)
      • Sarcoidosis
    • 5. Eje central en el diagnóstico es el TACAR
    • Demetds M, Eur Respir J. 2001
    — ENFERMEDAD PULMONAR DIFUSA + AR
  • M Hoeper. Eur Respir J. 2002
    • Compromiso pulmonar más frecuente
    • RA-ILD o EPD por AR
      • Tanoue LT. Pulmonary manifestations of rheumatoid arthritis. Clin Chest Med 1998
    • El patrón histológico de la EPD en el contexto de la AR, generalmente se asemeja a algún patrón de las NII (Neumonias Intersticiales Idiopáticas)
    • Usual interstitial pneumonia (UIP) *
    • Nonspecific interstitial pneumonia (NSIP) *
    • Organizing pneumonia (COP o BOOP)
    • Lymphocytic interstitial pneumonia(LIP)
    • Desquamative interstitial pneumonia (DIP)
    — ENFERMEDAD PULMONAR DIFUSA + AR
  • PATRONES DE EPD
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  • — ENFERMEDAD PULMONAR DIFUSA + AR
    • Compromiso es mayormente asintomático
    • Evaluado con Rx, TAC-AR, PFT, LBA entre 50-60% tiene algún grado de afección consistente con EPD
    • Este compromiso fue ( Gabbay Am J Respir Crit Care Med 1997)
      • asintomático 45%
      • aparente 15%
    Dong Soon. Curr Opin Pulm Med. 2006 50% DLCO 5!-80% TAC-AR 5-15% PFT 1-5% Rx EPD EXAMEN
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  • Park JH. Am J Respir Crit Care Med 2007 UIP no AR UIP AR
  • — ENFERMEDAD PULMONAR DIFUSA + AR
    • FACTORES DE RIESGO PARA RA-ILD
    • (predictores para desarrollarla)
    • Historia de tabaco
      • >25 paq/a OR 3.76 [1.59 - 8.88]
    • 2. Genética, HLA-DRB1
    • 3. Nódulos reumatoideos
    • 4. Hombre (3:1)
    • 5. Anti-CCP(+)
    • 6. Enfermedad seropositiva y erosiva
  • — ENFERMEDAD PULMONAR DIFUSA + AR
    • MANIFESTACIONES CLÍNICAS
      • Más frecuente 50-60ª de edad
      • Se presenta >5ª del compromiso articular
      • Disnea de esfuerzo (limitada por AR)
      • Tos no productiva
      • Poco frecuente: Fiebre, Dolor toraxico
      • Examen físico enfermedad establecida: No útil en screening
        • 1. Crujidos bibasales >75%
        • 2. Clubbing 75%
        • 3. HAP, ICD
    UpToDate 18.3. 2010
  • — ENFERMEDAD PULMONAR DIFUSA + AR
    • ESTUDIO
    • Rx Tórax, TAC-AR, FBC+LBA
      • PFTs, DLCO
    Gabbay. Am J Respir Crit Care Med 1997
  • — ENFERMEDAD PULMONAR DIFUSA + AR
    • TRATAMIENTO RA-ILD
    • Mayoría de pacientes tiene algún examen pulmonar alterado
    • Difícil seleccionar el subgrupo que se beneficia de tratamiento
      • Tratamientos poco efectivos
      • Debe instaurarse precozmente
      • Pacientes jóvenes
      • Deterioro pulmonar significativo (<3 Meses)
  • COMPROMISO PULMONAR AR, RX + TAC Current Opin Rheumatol 2008 60-90% Opacidades reticulares 28% Panal de abejas 28% Vidrio esmerilado 25% Atrapamiento aéreo 5-10-30% Nódulos 75% Bronquiectasias FRECUENCIA HALLAZGO
  • — ENFERMEDAD PULMONAR DIFUSA + AR
    • Respuesta según patrón histológico similar a EPD
    • 1. COP responden a corticoides
    • EPD AR tratamiento se evalúa a 3 MESES (PFTs)
    • continuar o suspender? (mantener Prednisona 0,25 mg/kg/dia?)
    • OPCIONES Rp
    • 1. Prednisona 0.5 mg/kg dia am
    • 2. Prednisona 20mg dia + Azatioprina 3 mg/kg ó CF 100-120 mg/dia
    • CONSIDERAR
    • 1. Pacientes en MTX pueden progresar más rápido de su EPD
    • - Interpretación: MTX no es beneficioso para Rp de EPD-RA
    • - Efecto de anti-TNF? Aceleran evolución?
    • 2. Monitorizar mensual: DLCO, PFTs
      • Compromiso de vía aérea
    COMPROMISO PULMONAR EN AR
      • HAP en AR
      • EPD en AR
      • Nódulos pulmonares en AR
      • Compromiso pleural
    1. Asociado a AR (Rheumatoid-associated lung disease )
  • M Hoeper. Eur Respir J. 2002 N Hill. Pulmonary Hypertension. Humana Press. 2008
    • <3-5% HAP considerado excepcional
      • HAP severa (daño vascular aislado) sin daño intersticial (EPD) solo a nivel de CASE REPORT
    • Generalmente en contexto de EPD
    • Mayoría de casos son leves o moderados (PASP <40mmHg)
    HAP en RA-ILD
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  • HIPERTENSIÓN PULMONAR
    • Hipertensión Arterial Pulmonar (PAH) es un síndrome producido por la restricción al flujo sanguíneo en la circulación arterial pulmonar, resultando en un aumento de la resistencia vascular pulmonar y finalmente en falla cardiaca derecha
    • Sobrevida media sin tratamiento en global 2,8a
    ACCF/AHA Expert Consensus Document on Pulmonary Hypertension. J. Am. Coll. Cardiol. 2009 * Con POAP <15 mmHg + RVP >3U woods (240 dyn·s/cm5 ) HTP >25 mmHg * Implicancia clínica incierta 21 – 24 mmHg Normal 8 – 20 mmHg CONDICIÓN mean PAP EN REPOSO
    • CTD Y FRECUENCIA DE HAP
    M Hoeper. Eur Respir J. 2002. N Hill. Pulmonary Hypertension. Humana Press. 2008 20-70% Enfermedad Mixta Tejido Conectivo ESP Difusa más frecuente EPD 10-15% Difusa 70-80% Limitada Esclerosis Sistémica Progresiva (ESP) FRECUENCIA HAP ENFERMEDAD Case Report Más frecuente en contexto de EPD Sd. Sjögren (SS) Case Report Polimiositis-Dermatomiositis (PM-DM) 5-20% Mayoría casos moderaros, asociados a TEP crónico Lupus Eritematoso Sistémico (LES) <5% generalmente en contexto de EPD Mayoría de casos son leves o moderados Artritis Reumatoidea (AR)
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  • D’ Alonzo GE. Ann Int Med. 1991 HAP, HISTORIA NATURAL
  • ACCF/AHA Expert Consensus Document on Pulmonary Hypertension. J. Am. Coll. Cardiol. 2009 HAP, SOBREVIDA SEGÚN ETIOLOGIA
  • ACCF/AHA Expert Consensus Document on Pulmonary Hypertension. J. Am. Coll. Cardiol. 2009 HAP, SOBREVIDA SEGÚN ETIOLOGIA HAP asociada a CTD es uno de los grupos con peor sobrevida
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      • Compromiso de vía aérea
    COMPROMISO PULMONAR EN AR
      • HAP en AR
      • EPD en AR
      • Nódulos pulmonares en AR
      • Compromiso pleural
    1. Asociado a AR (Rheumatoid-associated lung disease )
  • Obstrucción vía a 2 COMPROMISO VIA a 2 ALTA
    • Compromiso Cricoaritenoideo
      • Anquilosis, Nódulos
    • Más mujeres AR larga data
    • Laringoscopia + CT: 50-75%
    • Síntomas: 20-30%
    • Voz ronca, dolor, tos, disnea (OVA SUP)
    • Casos reportados hasta de ET** y obstrucción rápida
    • RP. Cx casos extremos, Agudo: TQT, Inalación helium-O2
  • UpToDate 18.3. 2010 Obstrucción vía a 2 COMPROMISO VIA a2 BAJA HiperRx. Ha sido controversial Cofounders TABACO + EPD: 60% Ajustado: 20% Etiología Multifactorial RP: Like-Asma
  • UpToDate 18.3. 2010
    • Frente a una paciente con AR y compromiso pulmonar tenemos las siguientes posibilidades, compromiso pulmonar:
    ARTRITIS REUMATOIDEA (AR) COMPROMISO PULMONAR EN AR 5. Síndrome de sobreposición (AR+ESP) 4. Condición médica co-existente (Asma, ICC, LCFA) 3. Infección 2ria a estado inmunosupresión 2. Asociado al tratamiento de la AR 1. Asociado a AR (Rheumatoid-associated lung disease )
  • DAÑO COLATERAL COMPROMISO PULMONAR POR TRATAMIENTO DE AR
    • Compromiso pulmonar derivado del tratamiento de la AR ha sido extensamente definido
    • Existen reportes de caso incluso de HAP en el contexto de terapia con Leflunomida para AR
    • METROTREXATO genera importante compromiso pulmonar.
    • Se describen 5 Síndromes clínicos pulmonares asociados a su uso
    V. M. Martinez-Taboada. Rheumatology 2004 CARACTERISTICAS DEL COMPROMISO PULMONAR DE MTX
    • Sintomatología en general incluye: Tos persistente no productiva y/o disnea
    • Toxicidad pulmonar no esta relacionada a dosis cumulativa
    • Relacionada a factores como edad avanzada, MTX por AR, Regímenes de drogas bisemanales, Uso de drogas que disminuyen la unión a A- del MTX (AAS, FNT, PNS, AINES, FNB)
    • 30% de los pacientes discontinúan el MTX al 5ª por efectos adversos
    COMPROMISO PULMONAR Rp AR
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  • FACTORES DE RIESGO PARA COMPROMISO PULMONAR DE MTX
  • G. Cannon. Rheumatic disease clinics of North America. 1997 SINDROMES PULMONARES POR MTX +F 2-5% Nódulos pulmonares Pleuritis, Derrame Pleural Edema Pulmonar Agudo No Cardiogénico EPD por MTX Neumonitis Aguda Intersticial (Rx HS)
  • NEUMONITIS por MTX
    • DATOS GENERALES
    • Más común 1er año de Rp
    • - Entre 1 y 5 Meses más Frecuente
    • Sin relación a dosis (HS)
    • 1-5% Pacientes
    • Mortalidad global 10%
    • CLINICA+DG
    • fiebre, disnea, tos, crépitos inspiratorios
    • Leucocitosis, EOS
    • Importante descartar infecicón oportunista (PCP, HD, HZ)
    • FBC-LBA
    • Linfocitos CD4/8+
  • NEUMONITIS por MTX
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  • Riesgo NEUMONITIS por MTX
  • NEUMONITIS por MTX
    • En que pacientes con AR evitar MTX
    • 1. EPD previa
    • 2. DLCO <70%
    • V Saravanan. Rheumatology 2004
    • RP NEUMONITIS
    • STOP MTX
    • Asistencia O2+Ventilatoria
    • Corticoides MP pulsos ev (sin GPC)?
    • CF?
  • V Saravanan. Rheumatology 2004
  • MTX + COMPROMISO PULMONAR
    • PATRONES
    • I (a) : Acute diffuse interstitial lung disease with often lymphocytosis in the BAL and respiratory failure. A pathologic pattern of nonspecific interstitial pneumonia is typically present
    • I (b) : Subacute diffuse interstitial pneumonia (a pattern similar to but less severe than 1a)
    • I (c) : Pulmonary infiltrates with eosinophilia, also called eosinophilic pneumonia (can be dense and severe, and occasion respiratory failure)
    • I (g) : Irreversible pulmonary fibrosis
    • I (l)* : Diffuse alveolar damage
    • I (m)* : Interstitial lung disease with a granulomatous pattern
    • II (a) : Acute pulmonary edema (typically noncardiac and reversible)
    • II (b) : Acute permeability edema with or without an ARDS pattern
    • III (a) : Diffuse alveolar hemorrhage (DAH)
    • IV (b) : Bronchospasm and angioedema with or without anaphylaxis features
    • IV (d) : Lone cough
    • V (a) : Pleural effusion, usually exudative
    • XI (b) : Chest pain
    • XI (e) : Opportunistic infectious pneumonia (including viral, bacterial, tuberculosis, pneumocystis carinii ...)
    http://www.pneumotox.com
  • MTX + COMPROMISO PULMONAR
    • PATRONES
    • I (a) : Acute diffuse interstitial lung disease with often lymphocytosis in the BAL and respiratory failure. A pathologic pattern of nonspecific interstitial pneumonia is typically present
    • I (b) : Subacute diffuse interstitial pneumonia (a pattern similar to but less severe than 1a)
    • I (c) : Pulmonary infiltrates with eosinophilia, also called eosinophilic pneumonia (can be dense and severe, and occasion respiratory failure)
    • I (g) : Irreversible pulmonary fibrosis
    • I (l)* : Diffuse alveolar damage
    • I (m)* : Interstitial lung disease with a granulomatous pattern
    • II (a) : Acute pulmonary edema (typically noncardiac and reversible)
    • II (b) : Acute permeability edema with or without an ARDS pattern
    • III (a) : Diffuse alveolar hemorrhage (DAH)
    • IV (b) : Bronchospasm and angioedema with or without anaphylaxis features
    • IV (d) : Lone cough
    • V (a) : Pleural effusion, usually exudative
    • XI (b) : Chest pain
    • XI (e) : Opportunistic infectious pneumonia (including viral, bacterial, tuberculosis, pneumocystis carinii ...)
    http://www.pneumotox.com PATRONES DIVERSOS. Más de 100 Referencias bibliográficas hacen relación al CPxMTX Principalmente Neumonitis Aguda Intersticial
  • MTX + COMPROMISO PULMONAR A Sikka. JIACM. 2006
  • C. Rayner, S. Grubnic. Best Practice & Research Clinical Rheumatology. 2004 ARTRITIS REUMATOIDEA (AR) EVALUACION PULMONAR
  • CONCLUSIONes
    • La afectacion pulmonar en AR es responsable de importante de morbimortalidad
    • Aunque la toxicidad de fármacos y las infecciones pueden ocasionar patología pulmonar, la afectación directamente asociada a AR es más común
    • Estructuras implicadas: vías respiratorias, vasos, parénquima y pleura
    • La EPD reduce la supervivencia y la calidad de vida en los pacientes con AR
    • La utilidad de las nuevas terapias biológicas actualmente es desconocida, se precisan más estudios
  • Muchas gracias por su atención foto de la vida real
  • COMPROMISO PULMONAR EN ARTRITIS REUMATOIDEA Muchas Gracias por su atención