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Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
Compromiso Pulmonar en ARTRITIS REUMATOIDEA
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Compromiso Pulmonar en ARTRITIS REUMATOIDEA

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Compromiso Pulmonar en ARTRITIS REUMATOIDEA
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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)
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Factors associated with interstitial pneumonitis after bone-marrow transplantation for acute leukemia. Lancet 1982; i: 437-43986. Camus P, Knopf J F, Olsson N O, Reybet-Degat O, Jeannin L. Pneumopathie au methotrexate, hypocomplémentémie et immuns complexes. Rev Fr Mal Respir 1981; 9: 64-6587. Camus P, Reybet-Degat O, Michiels R, Jeannin L. Pneumopathie au methotrexate associé à des agglutinines froides. Presse Med 1981; 9: 369888. Weiss J R, Bruno S. Hypersensitivity reactions to cancer chemotherapeutic agents. Ann Intern Med 1981; 94: 66-7289. Rohatgi P K, Halvarson L. Unilateral methotrexate-induced pneumonitis. J Natl Med Assoc 1980; 72: 896-89990. Bedrossian C W M, Miller W C, Luna M A. Methotrexate-induced diffuse interstitial pulmonary fibrosis. South Med J 1979; 72: 313-31891. Hanawa M, Fujisawa H. A case of interstitial pneumonitis induced by intrathecal injection of methotrexate. Nippon Kyobu Shikkan Gakkai Zasshi 1979; 17: 737-74192. Lewis W J, Walter J F. Methotrexate-induced pulmonary fibrosis. Arch Dermatol 1979; 115: 1169-117093. Verdich J, Christensen A L. Pulmonary disease complicating intermittent methotrexate therapy of psoriasis. Acta Derm Venerol (Stockh) 1979; 59: 471-47394. Guerra Tapia A, Moreno Izquierdo R, Barrio-Fuertes A, Merino Monge E. Fibrosis pulmonar debida a tratamiento con methotrexate. Acta Dermo-Sifiliogr 1978; 69: 301-30895. Kaplan R L, Waite D H. Progressive interstitial lung disease from prolonged methotrexate therapy. Arch Dermatol 1978; 114: 1800-180296. Lewis M J, Cameron A H, Stah K J, Purdham D R, Mann J R. Giant-cell pneumonia caused by measles and methotrexate in childhood leukemia in remission. Br Med J 1978; i: 330-33197. Sybert A, Butler T P. Sarcoidosis following adjuvant high- ose methotrexate therapy for osteosarcoma. Arch Intern Med 1978; 138: 488-48998. Lascari A D, Strano A J, Johnson W W, Collins J G P. Methotrexate-induced sudden fatal pulmonary reaction. Cancer 1977; 40: 1393-139799. Manni J J, van den Broek P. Pulmonary complications of methotrexate therapy. Clin Otolaryngol 1977; 2: 131-137100. Walden P A M, Mitchell-Heggs P F, Coppin C, Dent J, Bagshawe K D. Pleurisy and methotrexate treatment. Br Med J 1977; ii: 967101. Gutin P H, Green M R, Bleyer W A, Bauer V L, Wiernik P H, Walker M D. Methotrexate pneumonitis induced by intrathecal methotrexate therapy. A case report with parmacokinetic data. Cancer 1976; 38: 1529-1534102. Nesbit M, Krivit W, Heyn R, Sharp H. Acute and chronic effects of methotrexate on hepatic, pulmonary and skeletal systems. Cancer 1976; 37: 1048-1054103. Sostman H D, Matthay R A, Putman C E, Walker Smith G J. Methotrexate-induced pneumonitis. Medicine (Baltimore) 1976; 55: 371-388104. From E. Methotrexate pneumonitis in a psoriatic. Br J Dermatol 1975; 93: 107-110105. Bhat K S S, Anderson K R, Stewart R D H. Lung disease associated with methotrexate therapy. Aust NZ J Med 1974; 4: 277-280106. Bellini F, Masera G. Pulmonary disease complicating therapy with methotrexate. Ann Radiol 1973; 16: 267-271107. Everts C S, Wescott J L, Bragg D G. Methotrexate therapy and pulmonary disease. Radiology 1973; 107: 539-543108. Lisbona A, Schwartz J, Lachance C, Frank H, Palayew M J. Methotrexate-induced pulmonary disease. J Can Assoc Radiol 1973; 24: 215-220109. Robbins K M, Gribetz I, Strauss L, Leonidas J C, Sanders M. Pneumonitis in acute lymphatic leukemia during methotrexate therapy. J Pediatr 1973; 82: 84-88110. Whitcomb M E, Schwartz M I, Tormey D C. Methotrexate pneumonitis: case report and review of the literature. Thorax 1972; 27: 636-639111. Dietzsch H-J, Lorenz K, Roschlau G. Lungenveränderungen bei Methotrexate-Behandlung im Kindesalter. Dtsch Gesundh Wochenschr 1971; 26: 174-178112. Filip D J, Logue G L, Harle T S, Farrar W H. Pulmonary and hepatic complications of methotrexate therapy for psoriasis. JAMA 1971; 216: 881-882113. Pasquinucci G, Ferrara P, Castellari R. Daunorubicin treatment of methotrexate pneumonia. JAMA 1971; 216: 2017114. Rawbone R G, Shaw M T, Jackson J G, Bagshawe K D. Complication of methotrexate-maintained remission in lymphoblastic leukaemia. Br Med J 1971; 4: 467-468115. Robertson J H. Pneumonia and methotrexate. Br Med J 1970; 2: 156116. Clarysse A M, Cathey W J, Cartwright G E, Wintrobe M M. Pulmonary disease complicating intermittent therapy with methotrexate. JAMA 1969; 209: 1861-1864117. Schwartz I R, Kajani M K. Methotrexate therapy and pulmonary disease. JAMA 1969; 210: 1924
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Factors associated with interstitial pneumonitis after bone-marrow transplantation for acute leukemia. Lancet 1982; i: 437-43986. Camus P, Knopf J F, Olsson N O, Reybet-Degat O, Jeannin L. Pneumopathie au methotrexate, hypocomplémentémie et immuns complexes. Rev Fr Mal Respir 1981; 9: 64-6587. Camus P, Reybet-Degat O, Michiels R, Jeannin L. Pneumopathie au methotrexate associé à des agglutinines froides. Presse Med 1981; 9: 369888. Weiss J R, Bruno S. Hypersensitivity reactions to cancer chemotherapeutic agents. Ann Intern Med 1981; 94: 66-7289. Rohatgi P K, Halvarson L. Unilateral methotrexate-induced pneumonitis. J Natl Med Assoc 1980; 72: 896-89990. Bedrossian C W M, Miller W C, Luna M A. Methotrexate-induced diffuse interstitial pulmonary fibrosis. South Med J 1979; 72: 313-31891. Hanawa M, Fujisawa H. A case of interstitial pneumonitis induced by intrathecal injection of methotrexate. Nippon Kyobu Shikkan Gakkai Zasshi 1979; 17: 737-74192. Lewis W J, Walter J F. Methotrexate-induced pulmonary fibrosis. Arch Dermatol 1979; 115: 1169-117093. Verdich J, Christensen A L. Pulmonary disease complicating intermittent methotrexate therapy of psoriasis. Acta Derm Venerol (Stockh) 1979; 59: 471-47394. Guerra Tapia A, Moreno Izquierdo R, Barrio-Fuertes A, Merino Monge E. Fibrosis pulmonar debida a tratamiento con methotrexate. Acta Dermo-Sifiliogr 1978; 69: 301-30895. Kaplan R L, Waite D H. Progressive interstitial lung disease from prolonged methotrexate therapy. Arch Dermatol 1978; 114: 1800-180296. Lewis M J, Cameron A H, Stah K J, Purdham D R, Mann J R. Giant-cell pneumonia caused by measles and methotrexate in childhood leukemia in remission. Br Med J 1978; i: 330-33197. Sybert A, Butler T P. Sarcoidosis following adjuvant high- ose methotrexate therapy for osteosarcoma. Arch Intern Med 1978; 138: 488-48998. Lascari A D, Strano A J, Johnson W W, Collins J G P. Methotrexate-induced sudden fatal pulmonary reaction. Cancer 1977; 40: 1393-139799. Manni J J, van den Broek P. Pulmonary complications of methotrexate therapy. Clin Otolaryngol 1977; 2: 131-137100. Walden P A M, Mitchell-Heggs P F, Coppin C, Dent J, Bagshawe K D. Pleurisy and methotrexate treatment. Br Med J 1977; ii: 967101. Gutin P H, Green M R, Bleyer W A, Bauer V L, Wiernik P H, Walker M D. Methotrexate pneumonitis induced by intrathecal methotrexate therapy. A case report with parmacokinetic data. Cancer 1976; 38: 1529-1534102. Nesbit M, Krivit W, Heyn R, Sharp H. Acute and chronic effects of methotrexate on hepatic, pulmonary and skeletal systems. Cancer 1976; 37: 1048-1054103. Sostman H D, Matthay R A, Putman C E, Walker Smith G J. Methotrexate-induced pneumonitis. Medicine (Baltimore) 1976; 55: 371-388104. From E. Methotrexate pneumonitis in a psoriatic. Br J Dermatol 1975; 93: 107-110105. Bhat K S S, Anderson K R, Stewart R D H. Lung disease associated with methotrexate therapy. Aust NZ J Med 1974; 4: 277-280106. Bellini F, Masera G. Pulmonary disease complicating therapy with methotrexate. Ann Radiol 1973; 16: 267-271107. Everts C S, Wescott J L, Bragg D G. Methotrexate therapy and pulmonary disease. Radiology 1973; 107: 539-543108. Lisbona A, Schwartz J, Lachance C, Frank H, Palayew M J. Methotrexate-induced pulmonary disease. J Can Assoc Radiol 1973; 24: 215-220109. Robbins K M, Gribetz I, Strauss L, Leonidas J C, Sanders M. Pneumonitis in acute lymphatic leukemia during methotrexate therapy. J Pediatr 1973; 82: 84-88110. Whitcomb M E, Schwartz M I, Tormey D C. Methotrexate pneumonitis: case report and review of the literature. Thorax 1972; 27: 636-639111. Dietzsch H-J, Lorenz K, Roschlau G. Lungenveränderungen bei Methotrexate-Behandlung im Kindesalter. Dtsch Gesundh Wochenschr 1971; 26: 174-178112. Filip D J, Logue G L, Harle T S, Farrar W H. Pulmonary and hepatic complications of methotrexate therapy for psoriasis. JAMA 1971; 216: 881-882113. Pasquinucci G, Ferrara P, Castellari R. Daunorubicin treatment of methotrexate pneumonia. JAMA 1971; 216: 2017114. Rawbone R G, Shaw M T, Jackson J G, Bagshawe K D. Complication of methotrexate-maintained remission in lymphoblastic leukaemia. Br Med J 1971; 4: 467-468115. Robertson J H. Pneumonia and methotrexate. Br Med J 1970; 2: 156116. Clarysse A M, Cathey W J, Cartwright G E, Wintrobe M M. Pulmonary disease complicating intermittent therapy with methotrexate. JAMA 1969; 209: 1861-1864117. Schwartz I R, Kajani M K. Methotrexate therapy and pulmonary disease. JAMA 1969; 210: 1924
  • Transcript

    • 1. COMPROMISO PULMONAR EN ARTRITIS REUMATOIDEA Miércoles 23 de Junio 2010 Julián Vega Adauy , Residente Medicina Interna Universidad de Concepción PRESENTACION FINAL ROTACION REUMATOLOGIA
    • 2.  
    • 3. 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
    • 4. 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)
    • 5. ÍNDICE DE PRESENTACIÓN
      • Introducción,
      • Manifestaciones pulmonares CTD
      • Manifestaciones pulmonares de la AR
      • Enfermedad pulmonar difusa (EPD)
    • 6.
      • 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
    • 7.
      • 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
    • 8.
      • 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
    • 9. HIPERTENSIÓN PULMONAR 2ria EPD PRIMARIA (ASOCIADA) ETE crónica ENFERMEDAD TEJ CONECTIVO K. Fagan. Progress in Cardiovascular Diseases 2002
    • 10. E. Kim. Radiographics 2002 COMPROMISO PULMONAR Y CTD
    • 11.
      • 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)
    • 12. — INTRODUCCION K Brown. Proceedings ATS. 2007
    • 13. — INTRODUCCION K Brown. Proceedings ATS. 2007 IMPORTANCIA DEL COMPROMISO EXT-ART Claro impacto en mortalidad
    • 14.
      • 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
    • 15. ÍNDICE DE PRESENTACIÓN
      • Introducción, EPD, HTP
      • Manifestaciones pulmonares CTD
      • Manifestaciones pulmonares de la AR
      • Enfermedad pulmonar difusa (EPD)
    • 16. — 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
    • 17. PULMÓN REUMATOIDEO
    • 18. Current Opin Rheumatol 2008 COMPROMISO PULMONAR AR
    • 19. Current Opin Rheumatol 2008 COMPROMISO PULMONAR AR Variadas manifestaciones pleuro-pulmonares de la AR
    • 20. 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 )
    • 21.
        • 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 )
    • 22.
        • 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 )
    • 23.
      • 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
    • 24.
      • 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
    • 25. LIQUIDO PLEURAL EN DP x AR
    • 26.
      • 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
    • 27.  
    • 28. V Luiza. J. Pneumologia 2003
    • 29. V Luiza. J. Pneumologia 2003
    • 30. Source: Johns Hopkins Arthritis
    • 31.  
    • 32.  
    • 33. 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
    • 34. 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
    • 35.
        • 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 )
    • 36. COMPROMISO NODULAR PULMONAR No Neumocócicos (Necrobióticos) Neumocócicos (Sd. Caplan)
    • 37.
      • 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
    • 38. COMPROMISO NODULAR PULMONAR
    • 39.  
    • 40.  
    • 41.  
    • 42. COMPROMISO NODULAR PULMONAR
    • 43. COMPROMISO NODULAR PULMONAR
    • 44.  
    • 45.
      • 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
    • 46.  
    • 47.
        • 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 )
    • 48.  
    • 49.
      • 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
    • 50.
      • 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
    • 51. 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
    • 52. PATRONES DE EPD
    • 53.  
    • 54.  
    • 55.  
    • 56. — 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
    • 57.  
    • 58.  
    • 59. Park JH. Am J Respir Crit Care Med 2007 UIP no AR UIP AR
    • 60. — 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
    • 61. — 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
    • 62. — ENFERMEDAD PULMONAR DIFUSA + AR
      • ESTUDIO
      • Rx Tórax, TAC-AR, FBC+LBA
        • PFTs, DLCO
      Gabbay. Am J Respir Crit Care Med 1997
    • 63. — 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)
    • 64. 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
    • 65. — 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
    • 66.
        • 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 )
    • 67. 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
    • 68.  
    • 69. 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
    • 70.
      • 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)
    • 71.  
    • 72. D’ Alonzo GE. Ann Int Med. 1991 HAP, HISTORIA NATURAL
    • 73. ACCF/AHA Expert Consensus Document on Pulmonary Hypertension. J. Am. Coll. Cardiol. 2009 HAP, SOBREVIDA SEGÚN ETIOLOGIA
    • 74. 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
    • 75.  
    • 76.
        • 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 )
    • 77. 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
    • 78. 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
    • 79. 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 )
    • 80. DAÑO COLATERAL COMPROMISO PULMONAR POR TRATAMIENTO DE AR
    • 81.
      • 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
    • 82.  
    • 83.  
    • 84. FACTORES DE RIESGO PARA COMPROMISO PULMONAR DE MTX
    • 85. 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)
    • 86. 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+
    • 87. NEUMONITIS por MTX
    • 88.  
    • 89. Riesgo NEUMONITIS por MTX
    • 90. 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?
    • 91. V Saravanan. Rheumatology 2004
    • 92. 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
    • 93. 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
    • 94. MTX + COMPROMISO PULMONAR A Sikka. JIACM. 2006
    • 95. C. Rayner, S. Grubnic. Best Practice & Research Clinical Rheumatology. 2004 ARTRITIS REUMATOIDEA (AR) EVALUACION PULMONAR
    • 96. 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
    • 97. Muchas gracias por su atención foto de la vida real
    • 98. COMPROMISO PULMONAR EN ARTRITIS REUMATOIDEA Muchas Gracias por su atención

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