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Rheumatoid Nodules of the Lung
 Necrobiotic Nodules


General Considerations

  • Rare
  • Immune-mediated granulomas frequently with necrotic centers
  • They are almost always associated with long, standing active rheumatoid arthritis
  • More frequent in males with high titers for rheumatoid factor
  • Also more frequent in smokers and those who already have subcutaneous nodules
  • Rheumatoid nodules are most common subcutaneously
  • They may also occur in the lungs, heart and trachea
  • Incidence on chest x-ray in RA is less than 1%
    • Using CT, their incidence increases to 22-28%

Clinical Findings

  • Mostly asymptomatic
  • Sometimes cough
  • Hemoptysis
  • Chest pain

Imaging Findings

  • Rounded, multiple, subpleural
  • Rarely solitary
  • Middle and upper lung zones more common, except with Caplan Syndrome (with pneumoconiosis)
  • Up to 50% cavitate, frequently apical lesions, usually thick-walled with smooth inner margins
    • Cavities may then harbor aspergillosis
  • Also associated with pleural effusion and/or pneumothorax and bronchopleural fistula
  • Rarely calcify

Differential Diagnosis

  • Metastases
  • Granulomatosis with polyangiitis (Wegener’s)
  • Septic emboli

Treatment

  • Do not require a specific treatment
  • Intervention only when a complication occurs
  • Nodules may respond to methotrexate and/or steroids

Prognosis

  • May regress without treatment
  • Nodules may follow course of arthritis or behave independent of its course

Rheumatoid Nodules of the Lung

Rheumatoid Nodules of the Lung

Rheumatoid Nodules. Above: Frontal radiograph of chest shows innumerable nodules scattered throughout both lungs (white arrows). Below: Two images from a CT scan of the chest show the nodules are mostly subpleural in location (yellow arrows). Patient had a long-standing history of rheumatoid arthritis and nodules were unchanged for 6 years.
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Rheumatoid nodules: differential diagnosis and immunohistological findings.  EM Veys and F De Keyser. Ann Rheum Dis. 1993 September; 52(9): 625–626.

Rheumatoid Arthritis–related Lung Diseases: CT Findings. Ni Tanaka, JS Kim, JD Newell, KK Brown, CD Cool, R Meehan,  T Emoto, T Matsumoto and DA Lynch. July 2004 Radiology, 232, 81-91