A 55-year-old man with long-standing RA on methotrexate and adalimumab develops persistent dry cough, progressive dyspnoea, and bilateral basal crackles. HRCT chest shows bilateral lower lobe reticulation with honeycombing and traction bronchiectasis. The MOST likely pulmonary complication of RA is:
- A Methotrexate-induced pneumonitis
- B Usual interstitial pneumonia (UIP) pattern – RA-ILD ✓
- C Organising pneumonia due to adalimumab
- D Obliterative bronchiolitis
Explanation
RA-associated ILD most commonly manifests as the UIP pattern on HRCT, characterised by basal-predominant reticulation, honeycombing, and traction bronchiectasis without ground-glass predominance — identical to idiopathic pulmonary fibrosis. RA-UIP has a worse prognosis than other RA-ILD patterns (NSIP, OP). Methotrexate pneumonitis typically shows diffuse bilateral ground-glass opacities acutely with eosinophilia and responds to steroid withdrawal. Adalimumab rarely causes organising pneumonia (which presents with consolidation rather than honeycombing). Obliterative bronchiolitis causes obstructive rather than restrictive physiology.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.