Daniel Antunes Silva Pereira

Adalimumab-induced acute interstitial lung disease in a patient with rheumatoid arthritis

The use of immunobiological agents for the treatment of autoimmune diseases is increasing in medical practice. Anti-TNF therapies have been increasingly used in refractory autoimmune diseases, especially rheumatoid arthritis, with promising results. However, the use of such therapies has been associated with an increased risk of developing other autoimmune diseases. In addition, the use of anti-TNF agents can cause pulmonary complications, such as reactivation of mycobacterial and fungal infections, as well as sarcoidosis and other interstitial lung diseases (ILDs). There is evidence of an association between ILD and the use of anti-TNF agents, etanercept and infliximab in particular. Adalimumab is the newest drug in this class, and some authors have suggested that its use might induce or exacerbate preexisting ILDs. In this study, we report the first case of acute ILD secondary to the use of adalimumab in Brazil, in a patient with rheumatoid arthritis and without a history of ILD.

Lung-dominant connective tissue disease among patients with interstitial lung disease: prevalence, functional stability, and common extrathoracic features

OBJECTIVE: To describe the characteristics of a cohort of patients with lung-dominant connective tissue disease (LD-CTD). METHODS: This was a retrospective study of patients with interstitial lung disease (ILD), positive antinuclear antibody (ANA) results (≥ 1/320), with or without specific autoantibodies, and at least one clinical feature suggestive of connective tissue disease (CTD). RESULTS: Of the 1,998 patients screened, 52 initially met the criteria for a diagnosis of LD-CTD: 37% were male; the mean age at diagnosis was 56 years; and the median follow-up period was 48 months. During follow-up, 8 patients met the criteria for a definitive diagnosis of a CTD. The remaining 44 patients comprised the LD-CTD group, in which the most prevalent extrathoracic features were arthralgia, gastroesophageal reflux disease, and Raynauds phenomenon. The most prevalent autoantibodies in this group were ANA (89%) and anti-SSA (anti-Ro, 27%). The mean baseline and final FVC was 69.5% and 74.0% of the predicted values, respectively (p > 0.05). Nonspecific interstitial pneumonia and usual interstitial pneumonia patterns were found in 45% and 9% of HRCT scans, respectively; 36% of the scans were unclassifiable. A similar prevalence was noted in histological samples. Diffuse esophageal dilatation was identified in 52% of HRCT scans. Nailfold capillaroscopy was performed in 22 patients; 17 showed a scleroderma pattern. CONCLUSIONS: In our LD-CTD group, there was predominance of females and the patients showed mild spirometric abnormalities at diagnosis, with differing underlying ILD patterns that were mostly unclassifiable on HRCT and by histology. We found functional stability on follow-up. Esophageal dilatation on HRCT and scleroderma pattern on nailfold capillaroscopy were frequent findings and might come to serve as diagnostic criteria.

Interpretation of autoantibody positivity in interstitial lung disease and lung-dominant connective tissue disease.

The initial evaluation of patients with interstitial lung disease (ILD) primarily involves a comprehensive, active search for the cause. Autoantibody assays, which can suggest the presence of a rheumatic disease, are routinely performed at various referral centers. When interstitial lung involvement is the condition that allows the definitive diagnosis of connective tissue disease and the classical criteria are met, there is little debate. However, there is still debate regarding the significance, relevance, specificity, and pathophysiological role of autoimmunity in patients with predominant pulmonary involvement and only mild symptoms or formes frustes of connective tissue disease. The purpose of this article was to review the current knowledge of autoantibody positivity and to discuss its possible interpretations in patients with ILD and without clear etiologic associations, as well as to enhance the understanding of the natural history of an allegedly new disease and to describe the possible prognostic implications. We also discuss the proposition of a new term to be used in the classification of ILDs: lung-dominant connective tissue disease.

An Experimental Study of Added Mass on a Plunging Airfoil Oscillating with High Frequencies at High Angles of Attack

Experiments are conducted to measure the unsteady plunging forces on an airfoil at zero forward velocity. The aim is to investigate the variation of the added mass with the oscillation frequency of the wing section for various angles of attack. Data of the measured forces is presented and compared with predicted forces from potential flow approximations. The results show a significant departure from those estimates especially at the high frequencies. The results show that the added mass varies linearly with the frequency of the oscillations. Furthermore, the added mass is largest for the cases of 10 and 20 degrees angles of attack. These results raise the question of how to account for the unsteady flow generated by the airfoil motion.

Idiopathic pulmonary fibrosis can be a transient diagnosis

The association between antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis and interstitial lung disease (ILD) has recently been described, including another possible etiology for the UIP pattern. Here, we report the case of a patient with an initial diagnosis of IPF who later developed ANCA-positive vasculitis.A 62-year-old nonsmoking male patient, a bricklayer, presented with a one-year history of dry cough and slowly progressive dyspnea, classified as grade 2 on the modified Medical Research Council scale. He was being treated with omeprazole, bromopride, and simvastatin for gastroesophageal reflux disease and dyslipidemia. Pulmonary auscultation revealed crackles at both lung bases, and the SpO

Pulmonary involvement in rheumatoid arthritis: evaluation by radiography and spirometry

Abstract Objective: To determine whether simple diagnostic methods can yield relevant disease information in patients with rheumatoid arthritis (RA). Methods: Patients with RA were randomly selected for inclusion in a cross-sectional study involving clinical evaluation of pulmonary function, including pulse oximetry (determination of SpO2, at rest), chest X-ray, and spirometry. Results: A total of 246 RA patients underwent complete assessments. Half of the patients in our sample reported a history of smoking. Spirometry was abnormal in 30% of the patients; the chest X-ray was abnormal in 45%; and the SpO2 was abnormal in 13%. Normal chest X-ray, spirometry, and SpO2 were observed simultaneously in only 41% of the RA patients. A history of smoking was associated with abnormal spirometry findings, including evidence of obstructive or restrictive lung disease, and with abnormal chest X-ray findings, as well as with an interstitial pattern on the chest X-ray. Comparing the patients in whom all test results were normal (n = 101) with those in whom abnormal test results were obtained (n = 145), we found a statistically significant difference between the two groups, in terms of age and smoking status. Notably, there were signs of airway disease in nearly half of the patients with minimal or no history of tobacco smoke exposure. Conclusions: Pulmonary involvement in RA can be identified through the use of a combination of diagnostic methods that are simple, safe, and inexpensive. Our results lead us to suggest that RA patients with signs of lung involvement should be screened for lung abnormalities, even if presenting with no respiratory symptoms.Objective: To determine whether simple diagnostic methods can yield relevant disease information in patients with rheumatoid arthritis (RA).Methods: Patients with RA were randomly selected for inclusion in a cross-sectional study involving clinical evaluation of pulmonary function, including pulse oximetry (determination of SpO2, at rest), chest X-ray, and spirometry.Results: A total of 246 RA patients underwent complete assessments. Half of the patients in our sample reported a history of smoking. Spirometry was abnormal in 30% of the patients; the chest X-ray was abnormal in 45%; and the SpO2 was abnormal in 13%. Normal chest X-ray, spirometry, and SpO2 were observed simultaneously in only 41% of the RA patients. A history of smoking was associated with abnormal spirometry findings, including evidence of obstructive or restrictive lung disease, and with abnormal chest X-ray findings, as well as with an interstitial pattern on the chest X-ray. Comparing the patients in whom all test results were normal (n = 101) with those in whom abnormal test results were obtained (n = 145), we found a statistically significant difference between the two groups, in terms of age and smoking status. Notably, there were signs of airway disease in nearly half of the patients with minimal or no history of tobacco smoke exposure.Conclusions: Pulmonary involvement in RA can be identified through the use of a combination of diagnostic methods that are simple, safe, and inexpensive. Our results lead us to suggest that RA patients with signs of lung involvement should be screened for lung abnormalities, even if presenting with no respiratory symptoms.

Tracheobronchomalacia in a patient on invasive mechanical ventilation: the role of electrical impedance tomography in its detection and positive end-expiratory pressure titration.

Tracheobronchomalacia (TBM) is a disorder caused by weakness of the tracheal and bronchial walls, together with softening of the supporting cartilage, resulting in excessive expiratory collapse. (1) Although some individuals with TBM are asymptomatic, others present with symptoms such as dyspnea, hemoptysis, wheezing, and chronic cough. (1-3) Because the symptoms are nonspecific, TBM can be easily overlooked or misdiagnosed as other obstructive airway diseases, including asthma and COPD. (4) In TBM patients with acute respiratory failure, noninvasive ventilation is a therapeutic option, because positive end-expiratory pressure (PEEP) can prevent airway collapse. (5-7) Kandaswamy et al. (8) reported that, among patients with respiratory

Nonlinear airfoil torsional response induced by separated flows

Stall-induced vibrations are nonlinear aeroelastic phenomena. Helicopter rotors, wind turbine blades, or other rotating components interacting with an airflow may vibrate in stall condition. Despite a significant effort to model the aerodynamics associated to the stall or separated flows, nonlinear aeroelastic behavior prediction and analysis in such flow regime remain a formidable challenge. Another source of nonlinearity with influence to aeroelastic response may be associated to the structure dynamic response. The combination of both separated flow aerodynamics and structural nonlinearities lead to complex dynamics, for instance, bifurcations and chaos. The purpose of this work is to present the analysis of stall-induced vibrations, or separated flow effects, of an airfoil in pitching when concentrated nonlinearities are associated to the structural dynamics. Limit cycles oscillations at higher angles of attack and complex nonlinear features are analyzed for different representations for concentrated restoring pitching moment. The pitching-only typical section dynamics is coupled with an unsteady aerodynamic model based on BeddoesLeishmann semi-empirical approach to produce the proper framework for gathering time series of aeroelastic responses. The analyses are performed by checking the amplitude of the aeroelastic responses in limit cycle oscillations. Evolutions on limit cycles amplitudes are used to reveal bifurcation points also admitting Mach numbers range up to 0.7, thereby providing important information to assess, characterize, and qualify the nonlinear behavior associated with combinations of different forms to represent concentrated pitching spring of the typical section. The concentrate structural nonlinearities under investigation are the hardening and softening cubic, free-play, and hysteresis. Results reinforce that oscillations under the effects of stall are mostly determined by the flow field. The structural nonlinearities are most relevant at lower airspeeds. Different bifurcations can be observed in Mach evolutions of LCOs, in which structural effects can be important to delay its onset.

SAT0113 Pulmonary Involvement in Rheumatoid Arthritis: is There A Role for Low-Complexity Medical Tests?

Background Depending on the method of screening, approximately 50% of rheumatoid arthritis (RA) patients may exhibit lung involvement, but most cases are subclinical. Objectives To evaluate whether simple methods can yield relevant disease information from RA patients. Methods RA patients from a Brazilian single terciary center were randomly selected for a cross-sectional clinical pulmonary evaluation, rest pulse oximetry, chest X-ray (CXR) and spirometry. Based on a prevalence assumption for abnormal spirometry of 30%, the sample size estimated for 1,000 patients at regular follow-up was 245, with 5% precision. The study was approved by local research ethics committee. Written informed consent was obtained from all participants. Results A total of 246 RA patients underwent complete assessments. Half of the population reported tobacco exposure. Spirometry was abnormal in 30% of the patients; CXR was abnormal in 45%, and pulse oximetry was abnormal in 13%. Normal CXR, spirometry and oximetry were observed simultaneously in only 41% of the RA patients. Tobacco exposure was associated with abnormal (p=0.006), obstructive (p=0.02) and restrictive (p=0.045) spirometry, and with abnormal (p=0.0005) and interstitial-patterned CXR (p=0.01). After adjusting for confounders, abnormal medical were associated with male gender (p=0.025), older age (p=0.004), positive rheumatoid factor (p=0.0003), disease duration (p=0.016) and smoking (p<0.0001). Notably, signs of airway disease were observed in nearly half of the patients with low or absent tobacco exposure. Conclusions A combination of simple, non-hazardous, inexpensive pulmonary evaluation methods can diagnose pulmonary disease in RA patients. Our results lead us to suggest that asymptomatic patients with mild lung involvement should undergo regular pulmonary evaluations, with further investigation if new symptoms develop or in the case of disease progression. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6050