Rheumatoid or Methotrexate Induced Interstitial Lung Disease? – A Clinical Dilemma

Rheumatoid arthritis (RA)–associated interstitial lung disease (RA-ILD) is an increasingly common extra-articular cause of mortality and morbidity in RA. Here, we present the case of an 82-year-old female suffering from RA-ILD. She presented with a 20-year history of RA with new-onset progressively worsening dyspnoea, pyrexia, and dry cough, which were not responsive to initial antibiotics. Moreover, she had been on long-term methotrexate, which can cause pulmonary disease. Investigations revealed raised inflammatory markers, restrictive lung patterns, and radiological features of ILD. She was treated with a tapering course of oral prednisolone and home oxygen, which provided some symptomatic improvement. Diagnosis of RA-ILD can be challenging due to several contributing factors. Optimal treatment is controversial, and corticosteroids have been widely used but with limited effects. There is evidence directed at potential therapeutic benefit from a number of newer agents, which are discussed.