EpistemisBasal symmetrical bilateral Velcro-type crackles in rheumatoid arthritis
Specialty: Respiratory.
Why it occurs
- Diffuse fibrosing interstitial pneumonia of the usual interstitial pneumonia (UIP) or non-specific interstitial pneumonia (NSIP) secondary to active or latent rheumatoid arthritis (chronic immune-mediated inflammation and progressive deposition of collagen tissue at the bases of both lungs symmetrically causes the noisy opening of the bronchioles and alveoli at the end of inspiration, auscultated as dry Velcro-type crackles symmetrical basal persistents)
- Progressive pulmonary fibrosis associated with rheumatoid arthritis with rheumatoid factor and anti-CCP at high titers.
Initial workup
High-resolution chest computed tomography (CT) (HRCT) without contrast; Forced spirometry with whole body plethysmography and diffusing capacity for carbon monoxide (DLCO); Transthoracic Doppler echocardiogram; Blood analysis with rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies; 6 minute walk test.
red flags
Rapid worsening of usual dyspnea at rest, oxygen saturation below 89% during walking or mild physical exertion, appearance of signs of associated severe pulmonary hypertension (accentuated second heart sound, malleolar edema), or intractable dry cough.
Standard management
- Methotrexate — 7.5-15 mg orally once a week, closely monitoring lung function, as it may rarely induce acute pulmonary toxicity
- Prednisone — 20-40 mg orally daily if there is a predominant active inflammatory component
- Nintedanib (150 mg orally every 12 hours to slow the loss of lung function in these patients).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Respiratory
- Listed causes
- 2
- Treatment options
- 3