Diagnostic approaches and treatments of systemic sclerosis patient with interstitial lung disease

Background: Systemic sclerosis or scleroderma is a rare disease with multiple complications which may include interstitial lung disease. The findings of diffuse type of systemic sclerosis, moderate restriction in pulmonary function test, interstitial pneumonia in chest x-ray, and ground glass opacity in thoracic CT-scan establish the diagnosis of interstitial lung disease associated with systemic sclerosis. We present a case of interstitial lung disease in a systemic sclerosis case, which was approached and treated comprehensively to slow the progression. Case Presentation: A 40-year-old female was admitted to the rheumatology polyclinic of Dr. Soetomo Hospital Surabaya with persistent dry cough for two years in June 2021. The patient also complained of breathlessness, painful joints, swollen knees, and morning stiffness three months prior to admission. The positive results of antinuclear antibody and rheumatoid factor were identified in 2016, which suggested autoimmune disease of scleroderma and being treated with azathioprine 50 mg twice a day, methylprednisolone 4 mg once a day, chloroquine 200 mg once a day, and calcium lactate once a day. The examinations in 2020 showed moderate restriction from the pulmonary function test, bilateral lung parenchymal infiltrates from the chest x-ray, and ground-glass opacity from the chest computed tomography scan (CT-scan). The patient was monthly prescribed cyclophosphamide 500 mg intravenously for six months as the substitution of azathioprine, methylprednisolone 4 mg once a day, and aspirin 100 mg once a day. The latest worsening condition led the patient to receive the substitution of cyclophosphamide which was mycophenolate mofetil 360 mg twice a day, along with aspirin 100mg and methylprednisolone 4 mg once a day, respectively. Conclusion: As a rare disease, the complications of systemic sclerosis should be anticipated. In this case, interstitial lung disease occurred following nearly five years of systemic sclerosis course which required immunosuppressive agents to enhance the efficacy of treatment. Comprehensive treatment with tight monitoring is necessary to slow the disease progression.