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Q. Can latent TB scaring be misdiagnosed as interstitial lung disease with RA?

Answered by
Dr. Zubayeralam
and medically reviewed by Dr. Vinodhini. J
This is a premium question & answer published on Apr 19, 2020 and last reviewed on: May 02, 2020

Hello doctor,

I am a 67-year-old female. I have a significant past medical history of TB and a lifetime history of bronchitis. My arthritis is currently being treated with Remicade. Last month, while in a temporary job I developed severe altitude sickness (SOB, fatigue, and confusion) followed by bronchitis (stuffy nose and productive cough). While there I needed to schedule a Remicade infusion and the doctor there said she heard crackles in my lungs and sent me for an immediate chest x-ray, high-resolution CT scan and a multitude of labs.

To my surprise, I was diagnosed with RA, not PSA as my rheumatologist had diagnosed me before itself. Anyway, the radiology results state honeycomb lung damage amongst other ominous findings. At my follow up I was told I have RA-ILD. I am now back to my place and have no symptoms to alert me of any lung problems. I followed up with my PCP last week and she did not hear crackles in my lungs. My peak flow rate is 400 and my O2 sat is 100% at rest and 98% with fast walking. I will send my radiology report and lab results.

My question is, can the latent TB lung scaring be misdiagnosed as RA-ILD or IPF? I would appreciate your opinion.

#

Hello,

Welcome to icliniq.com.

I can understand your concern. According to your statement, you have been suffering from chronic bronchitis with rheumatoid arthritis with recently diagnosed with RA related interstitial lung disease or idiopathic pulmonary fibrosis. You had a history of PTB and taking anti-tubercular drugs. You are concerned about your recent diagnosis based on HRCT chest whether it is RA-ILD/IPF or latent TB related complications for your past sufferings and now you feel a lot better.

Your HRCT of chest reveals (attachment removed to protect patient identity), interstitial fibrosis characterized by peripheral traction bronchiectasis, irregular reticulation in all lobes, microtubules with calcification in mid and lower lungs, lower lobe predominant microcystic changes without significant ground glass opacifications, hilar calcified lymph nodes consistent with chronic granulomatous disease, and bronchial wall thickening bilaterally.

Similar type of radiological findings can be found in post TB fibrosis, chronic obstructive pulmonary disease which includes two key components chronic bronchitis and emphysema, RA-ILD or IPF, etc. You may not tell your doctor about your previous history of Latent TB. For that reason his diagnosis was RA-ILD or IPF as you are suffering from RA. So he was not wrong as your radiological reports suggest the above mentioned differential diagnosis. Again, on high altitude, your doctor found crackles as you are suffering from COPD and it may be associated with infections that time and now it not heard as your infection was subsided.

Thank you doctor,

The rheumatologist in AZ was aware of my TB history but still said this is RA-ILD. I have researched RA-ILD and IPF and found it is terminal within three years. Is this correct? If this IS from my TB episode 30 years ago do you think this is still stable or could it now be progressive and terminal?

#

Hello,

Welcome back to iclniq.com.

According to your query, people who develop RA related ILD have a median survival rate of 3.2 years to 8.1 years from the time of diagnosis as some research shows. Further lung complications can develop and become increasingly severe. According to arthritis society 10% of people who have RA can be affected by ILD or IPF as a complication of RA. But you can reduce your risk by not smoking and by getting regular checkups to monitor breathing and check for lung problems. When a doctor can diagnose rheumatoid lung disease early it may be easier to treat and thus help to increase median survival rate like you. Your rheumatologist gave you some medications like a steroid to reduce its progress. Due to ILD or IPF, if scar tissue has built up in your lungs it will stay but the medications will slow down the process. Do not worry about it.

It is possible to catch TB more than once, if you are unlucky enough to breathe in TB bacteria at another time. Always take new TB symptoms seriously and get them checked out by a doctor as CDC tells even TB germs in your body are dormant and they are very strong. Many germs are killed after taking antitubercular drugs but some stay alive in your body for a long time. If those people suffer from any autoimmune disorder like RA can wake up the dormant TB germ when body immunity systems are declined. ILD or IPF can be a long term complication of PTB. You are using medications like Infliximab and it can cause ILD and TB too.


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