British Journal of Rheumatology 1992;31:691-693
BRONCHIECTASIS AND RHEUMATOID DISEASE: IS THERE AN ASSOCIATION? BY T. SOLANKI AND E. NEVILLE Department of Respiratory Medicine, St Mary's Hospital, Milton Road, Portsmouth PO3 6AD
SUMMARY Rheumatoid arthritis is associated with a number of pleuropulmonary disorders. A retrospective study of the frequency of rheumatoid disease in patients with bronchiectasis and pulmonaryfibrosiswas performed. The results suggest that the frequency of bronchiectasis and rheumatoid disease is similar to that of the well established, but rare, association between pulmonary fibrosis and rheumatoid arthritis. We therefore suggest that bronchiectasis should be remembered as a pulmonary association of rheumatoid disease which occurs as commonly as pulmonary fibrosis. Arthritis, Bronchiectasis, Pulmonary fibrosis.
(b) In the presence of a history of continuous or intermittent cough, productive of purulent sputum with repeated respiratory infection or haemoptysis, with physical signs consistent with the diagnosis and an abnormal chest radiograph due to localized collapse or shrinkage, definite cystic change or diffuse shadowing. (2) Probable (a) In the presence of a strongly suggestive plain radiograph, but without a typical history. (b) A typical history without radiographic abnormalities. (3) Possible Localized shrinkage on chest radiograph without symptoms suggestive of the diagnosis. Pulmonary fibrosis was diagnosed in the presence of clinical (dry cough, dyspnoea, fine crackles, with or without central cyanosis or finger clubbing) and radiological evidence together with a restrictive defect and reduced gas transfer factor. The diagnosis of rheumatoid arthritis was based on the 1987 based criteria of the American Rheumatism Association [14]. A note was also made of the smoking and drug history. RESULTS Four patients had definite bronchiectasis (as defined by Walker) and rheumatoid arthritis (Table I). In the pulmonaryfibrosisgroup, only four patients had rheumatoid arthritis. Thus, four of 77 (5.2%) bronchiectasis patients and four of 86 (4.7%) patients with pulmonaryfibrosishad rheumatoid arthritis. However, five of 77 (6.5%) bronchiectasis patients and seven of 86 (8.1%) patients with pulmonary fibrosis were rheumatoid factor positive. Details of a fifth seropositive patient with bronchiectasis, but no arthritis, are also given (Table I). The age range of the four bronchiectasis patients was 48-83 years; all four patients were female. The time interval between the onset of bronchiectasis and rheumatoid arthritis was 1-34 years (mean 19 years).
THE commonly accepted pleuropulmonary complications of rheumatoid disease are: pleurisy with or without effusions, rheumatoid nodules, pulmonary fibrosis, Caplan's syndrome and obliterative bronchiolitis [1]. Patients with rheumatoid disease are more susceptible to a variety of infections and, in autopsy studies, pneumonia was a common finding in rheumatoid subjects [2-6]. Despite interest in the possible association between rheumatoid disease and bronchiectasis in earlier years [7,8], this relationship is infrequently recognized in current clinical practice. In order to prove an association between rheumatoid disease and bronchiectasis, either very large numbers of patients with rheumatoid disease must be studied [9-11] or the frequency of the more common condition (rheumatoid) in a group of patients with the less common disorder (bronchiectasis) must be analysed [1]. The frequency of rheumatoid arthritis in the UK is 3% [12] and bronchiectasis is 0.13% [13]. Pulmonary fibrosis is a rare, but well recognized, complication of rheumatoid disease [1]. We therefore studied patients with bronchiectasis and pulmonary fibrosis and analysed the frequency of rheumatoid disease within these cohorts. PATIENTS AND METHOD A retrospective review of 77 patients with bronchiectasis and 86 patients with pulmonary fibrosis who were under active follow-up was performed. The patients in both groups had been referred for assessment of their respiratory symptoms. It was the clinic's practice to follow up all patients with diagnoses of either bronchiectasis or pulmonary fibrosis at least annually. The diagnosis of bronchiectasis was based on Walker's classification [8]. (1) Definite (a) If proven by bronchography. Submitted 12 March; revised version accepted 30 September 1991. Correspondence to Dr E. Neville.
© 1992 British Society for Rheumatology
0263-7103/92/010691 + 03 $08.00/0 691
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Birmingham on September 1, 2015
KEY WORDS:
692
BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 10 TABLE I RHEUMATOID FEATURES OF PATIENTS WITH BRONCHIECTASIS
Patients' age and sex
Age of onset of Rh disease
Rh latex
SCAT titre
Interval between diagnosis of bronchiectasis and Rh disease
F, 68 F, 48 M,83 F, 54 F, 65
67 46 83 54 No symptoms
+ve +ve +ve +ve +ve
6400 2500 100 25 50
1 year 27 years 34 years 33 years
1 2 3 4 5
DISCUSSION Rheumatoid arthritis is a common disease affecting approximately 3% of the British population and 70% of patients are female [12]. Some of thepleuropulmonary associations are well recognized [1]. Bronchiectasis in patients with rheumatoid disease drew considerable interest earlier this century. Brannan et al. [6] found four cases among 76 patients with rheumatoid arthritis on whom autopsy was performed. In 1955, Aronoff et al. [7] found bronchiectasis in six of 253 patients with rheumatoid disease and in their radiographic study of 130 patients, there were four with bronchiectasis compared with two in the control group. Walker [8] found the incidence of bronchiectasis to be 3.1% in rheumatoid arthritis compared to 0.3% in patients with osteoarthritis. He also noted that the incidence among newly referred patients with rheumatoid arthritis was 3.2%, demonstrating that the association was not spuriously related to more careful follow-up of patients with these two diseases. The incidence of pulmonary
fibrosis in the same study was 1.6%. In the present study the frequency of bronchiectasis and rheumatoid arthritis was 5.2% compared with 4.7% for pulmonary fibrosis and rheumatoid arthritis. Bronchiectasis preceded rheumatoid arthritis by a period of 1-34 years (mean 19 years) in the present study. Walker [8] reported that bronchiectasis preceded arthritis by a mean of 36.5 years in men and 28.5 years for women. There are no specific features distinguishing bronchiectasis in patients with rheumatoid disease from other causes of bronchiectasis. The precise cause of the association is unknown. It is possible that organisms present in chronically infected sputum trigger off rheumatoid arthritis [15]. A recent study has implicated Proteus mirabilis as a possible cause of rheumatoid arthritis [16] and this may explain the onset of rheumatoid arthritis after bronchiectasis. Some patients with bronchiectasis due to cystic fibrosis may develop arthritis [17], but this is seronegative and episodic, implying a different disease process and thus carrying no implications for the mechanism of association of bronchiectasis and rheumatoid disease. In one study, patients with bronchiectasis had IgM rheumatoid factor in 52% of cases, but there was no evidence that this represented a 'pre-arthritic' state [18]. Walker proposed that general practitioners may more readily refer patients with bronchiectasis to the rheumatology clinic because of the risk of steroid therapy. However, there was no evidence for this in his study and it does not apply to the present study.
TABLE II RESPIRATORY FEATURES OF FIVE PATIENTS WITH BRONCHIECTASIS AND RHEUMATOID DISEASE
Patient age and sex
Age of first chest symptoms
1
F, 68
2
2
F. 48
Not available
Age b/ectasis diagnosed and method
Smoker
Clubbing
66 Sputum. CXR. chest crackles
Yes
Yes
19
No
No
Yes
Yes
No
No
No
No
Bronchogram 3
M.83
48
4
F. 54
3
5
F. 65
47
49
Sputum, CXR. chest crackles 20 Bronchogram 63 Sputum, CXR, chest crackles
CXR/ bronchogram
FEV, (1)
FVC (1)
FER (%)
RLZ shadowing
0.65
1.80
33
RLZ Shadowing bilateral tubular B'ectasis Bilateral LZ shadowing
2.60
3.10
84
1.75
2.20
75
B'ectasis left lung + RLL Bilateral mid + lower zone shadowing
0.55
1.71
32
2.24
2.85
79
CXR. chest radiograph; FEV,. forced expiratory volume in one second: FVC. forced vital capacity: FER. forced expiratory ratio
(FEWVC %).
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Birmingham on September 1, 2015
Smoking did not appear to be a significant factor; only two patients with bronchiectasis had ever smoked. All patients had characteristic coarse basal crackles, but only two had finger nail clubbing. Spirometry was abnormal in all cases, but there was no consistent pattern (Table II). All four patients had a symmetrical peripheral polyarthropathy affecting the small joints of the hands. Only two patients had rheumatoid nodules.
SOLANKI AND NEVILLE: BRONCHIECTASIS AND RHEUMATOID DISEASE
REFERENCES
1 Turner-Warwick M, Courtney-Evans R. Pulmonary manifestations of rheumatoid disease. Clin Rheum Dis 1977;3:549-64. 2. Kuhns TG, Joplin RJ. Convalescent care in chronic arthritis. N EnglJ Med 1936;215:268-72. 3. Baggenstoss AH, Rosenberg EF. Visceral lesions associated with chronic infectious (rheumatoid) arthritis. Arch Pathol 1943;35:503-16. 4. Bennett GA. Comparison of the pathology of rheumatic fever and rheumatoid arthritis. Ann Intern Med 1943;19:111-13. 5. Fingerman DL, Andrus FC. Visceral lesions associated with rheumatoid disease. Ann Rheum Dis 1943 ;3:168-81. 6. Brannan HM, Good CA, Divertie MB, Baggenstoss AH. Pulmonary disease associated with rheumatoid arthritis. JAMA 1964;189:914-18. 7. Aronoff A, Bywaters EGL, Fearnley GR. Lung
lesions in rheumatoid arthritis. Br Med J 1955;2:228-32. 8. Walker WC. The lung in rheumatoid arthritis. MD thesis. University of Edinburgh, 1966. 9. Horler AR, Thompson M. The pleural and pulmonary complications of rheumatoid arthritis. Ann Intern Med 1959;51:1179-203. 10. Cruickshank B. Interstitial pneumonia and its consequences in rheumatoid disease. Br J Dis Chest 1959;53:226-36. 11. Patterson CD, Harville WE, Pierce JA. Rheumatoid lung disease. Ann Intern Med 1965;62:685-97. 12. Thompson M. Rheumatoid arthritis. In: Reports on rheumatic diseases. 2nd ed. London: ARC, 1977: 6-10. 13. Wynn-Williams N. Bronchiectasis: a study centred on Bedford and its environs. Br Med J 1953;l:1194-9. 14. Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987, revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315-24. 15. Lewis Faning E. Report on an enquiry into the aetiological factors associated with rheumatoid arthritis. Ann Rheum 1950;D9:(suppl). 16. Ebringer A, Khalafpour S, Wilson C. Rheumatoid arthritis and Proteus: a possible aetiological association. Rheumatollnt 1989;9:223-8. 17. Schidlow DV, Goldsmith DP, Palmer J, Huang NN. Arthritis in cystic fibrosis. Arch Dis Child 1984;59:377-9. 18. Hilton AM, Doyle L. Immunological abnormalities in bronchiectasis with chronic bronchial suppuration. Br J Dis Chest 1978;72:207-16. 19. Stack BH, Grant IWB. Rheumatoid interstitial lung disease. Br J Dis Chest 1965,59:202-11. 20. Miall WE. Rheumatoid arthritis in males. Epidemiological study of a Welsh mining community. Ann Rheum Dis 1955; 14:150-8.
ANNOUNCEMENT SECOND JENNER INTERNATIONAL GLYCOIMMUNOLOGY MEETING The Second Jenner International Glycoimmunology Meeting will be held at St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE on the 1st and 2nd November 1992. Further details are available from: Susan Henderson, Academic Rheumatology Unit, Division of Immunology, St George's Hospital Medical School, Cranmer Terrace, London SW170RE. Tel: 0816729944 ext 55795; Fax: 081 784 2649.
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Birmingham on September 1, 2015
Previously, the association between rheumatoid disease and bronchiectasis had been discounted on the argument that pulmonary tuberculosis was commoner in patients with rheumatoid disease [19,20] and that the bronchiectasis was related to tuberculosis. There was no historical or radiographic evidence of previous tuberculosis in the present study, all cases having basal bronchiectasis. In the present study, the frequency of bronchiectasis in rheumatoid patients was similar to that of the commonly accepted, though rare, association between pulmonary fibrosis and rheumatoid arthritis. We therefore suggest that this is a real, rather than a spurious, association and that bronchiectasis ought still to be considered a relatively common pleuropulmonary association of rheumatoid disease in the 1990s.
693
BRONCHIECTASIS AND RHEUMATOID DISEASE: IS THERE AN ASSOCIATION? BY T. SOLANKI AND E. NEVILLE Department of Respiratory Medicine, St Mary's Hospital, Milton Road, Portsmouth PO3 6AD
SUMMARY Rheumatoid arthritis is associated with a number of pleuropulmonary disorders. A retrospective study of the frequency of rheumatoid disease in patients with bronchiectasis and pulmonaryfibrosiswas performed. The results suggest that the frequency of bronchiectasis and rheumatoid disease is similar to that of the well established, but rare, association between pulmonary fibrosis and rheumatoid arthritis. We therefore suggest that bronchiectasis should be remembered as a pulmonary association of rheumatoid disease which occurs as commonly as pulmonary fibrosis. Arthritis, Bronchiectasis, Pulmonary fibrosis.
(b) In the presence of a history of continuous or intermittent cough, productive of purulent sputum with repeated respiratory infection or haemoptysis, with physical signs consistent with the diagnosis and an abnormal chest radiograph due to localized collapse or shrinkage, definite cystic change or diffuse shadowing. (2) Probable (a) In the presence of a strongly suggestive plain radiograph, but without a typical history. (b) A typical history without radiographic abnormalities. (3) Possible Localized shrinkage on chest radiograph without symptoms suggestive of the diagnosis. Pulmonary fibrosis was diagnosed in the presence of clinical (dry cough, dyspnoea, fine crackles, with or without central cyanosis or finger clubbing) and radiological evidence together with a restrictive defect and reduced gas transfer factor. The diagnosis of rheumatoid arthritis was based on the 1987 based criteria of the American Rheumatism Association [14]. A note was also made of the smoking and drug history. RESULTS Four patients had definite bronchiectasis (as defined by Walker) and rheumatoid arthritis (Table I). In the pulmonaryfibrosisgroup, only four patients had rheumatoid arthritis. Thus, four of 77 (5.2%) bronchiectasis patients and four of 86 (4.7%) patients with pulmonaryfibrosishad rheumatoid arthritis. However, five of 77 (6.5%) bronchiectasis patients and seven of 86 (8.1%) patients with pulmonary fibrosis were rheumatoid factor positive. Details of a fifth seropositive patient with bronchiectasis, but no arthritis, are also given (Table I). The age range of the four bronchiectasis patients was 48-83 years; all four patients were female. The time interval between the onset of bronchiectasis and rheumatoid arthritis was 1-34 years (mean 19 years).
THE commonly accepted pleuropulmonary complications of rheumatoid disease are: pleurisy with or without effusions, rheumatoid nodules, pulmonary fibrosis, Caplan's syndrome and obliterative bronchiolitis [1]. Patients with rheumatoid disease are more susceptible to a variety of infections and, in autopsy studies, pneumonia was a common finding in rheumatoid subjects [2-6]. Despite interest in the possible association between rheumatoid disease and bronchiectasis in earlier years [7,8], this relationship is infrequently recognized in current clinical practice. In order to prove an association between rheumatoid disease and bronchiectasis, either very large numbers of patients with rheumatoid disease must be studied [9-11] or the frequency of the more common condition (rheumatoid) in a group of patients with the less common disorder (bronchiectasis) must be analysed [1]. The frequency of rheumatoid arthritis in the UK is 3% [12] and bronchiectasis is 0.13% [13]. Pulmonary fibrosis is a rare, but well recognized, complication of rheumatoid disease [1]. We therefore studied patients with bronchiectasis and pulmonary fibrosis and analysed the frequency of rheumatoid disease within these cohorts. PATIENTS AND METHOD A retrospective review of 77 patients with bronchiectasis and 86 patients with pulmonary fibrosis who were under active follow-up was performed. The patients in both groups had been referred for assessment of their respiratory symptoms. It was the clinic's practice to follow up all patients with diagnoses of either bronchiectasis or pulmonary fibrosis at least annually. The diagnosis of bronchiectasis was based on Walker's classification [8]. (1) Definite (a) If proven by bronchography. Submitted 12 March; revised version accepted 30 September 1991. Correspondence to Dr E. Neville.
© 1992 British Society for Rheumatology
0263-7103/92/010691 + 03 $08.00/0 691
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Birmingham on September 1, 2015
KEY WORDS:
692
BRITISH JOURNAL OF RHEUMATOLOGY VOL. XXXI NO. 10 TABLE I RHEUMATOID FEATURES OF PATIENTS WITH BRONCHIECTASIS
Patients' age and sex
Age of onset of Rh disease
Rh latex
SCAT titre
Interval between diagnosis of bronchiectasis and Rh disease
F, 68 F, 48 M,83 F, 54 F, 65
67 46 83 54 No symptoms
+ve +ve +ve +ve +ve
6400 2500 100 25 50
1 year 27 years 34 years 33 years
1 2 3 4 5
DISCUSSION Rheumatoid arthritis is a common disease affecting approximately 3% of the British population and 70% of patients are female [12]. Some of thepleuropulmonary associations are well recognized [1]. Bronchiectasis in patients with rheumatoid disease drew considerable interest earlier this century. Brannan et al. [6] found four cases among 76 patients with rheumatoid arthritis on whom autopsy was performed. In 1955, Aronoff et al. [7] found bronchiectasis in six of 253 patients with rheumatoid disease and in their radiographic study of 130 patients, there were four with bronchiectasis compared with two in the control group. Walker [8] found the incidence of bronchiectasis to be 3.1% in rheumatoid arthritis compared to 0.3% in patients with osteoarthritis. He also noted that the incidence among newly referred patients with rheumatoid arthritis was 3.2%, demonstrating that the association was not spuriously related to more careful follow-up of patients with these two diseases. The incidence of pulmonary
fibrosis in the same study was 1.6%. In the present study the frequency of bronchiectasis and rheumatoid arthritis was 5.2% compared with 4.7% for pulmonary fibrosis and rheumatoid arthritis. Bronchiectasis preceded rheumatoid arthritis by a period of 1-34 years (mean 19 years) in the present study. Walker [8] reported that bronchiectasis preceded arthritis by a mean of 36.5 years in men and 28.5 years for women. There are no specific features distinguishing bronchiectasis in patients with rheumatoid disease from other causes of bronchiectasis. The precise cause of the association is unknown. It is possible that organisms present in chronically infected sputum trigger off rheumatoid arthritis [15]. A recent study has implicated Proteus mirabilis as a possible cause of rheumatoid arthritis [16] and this may explain the onset of rheumatoid arthritis after bronchiectasis. Some patients with bronchiectasis due to cystic fibrosis may develop arthritis [17], but this is seronegative and episodic, implying a different disease process and thus carrying no implications for the mechanism of association of bronchiectasis and rheumatoid disease. In one study, patients with bronchiectasis had IgM rheumatoid factor in 52% of cases, but there was no evidence that this represented a 'pre-arthritic' state [18]. Walker proposed that general practitioners may more readily refer patients with bronchiectasis to the rheumatology clinic because of the risk of steroid therapy. However, there was no evidence for this in his study and it does not apply to the present study.
TABLE II RESPIRATORY FEATURES OF FIVE PATIENTS WITH BRONCHIECTASIS AND RHEUMATOID DISEASE
Patient age and sex
Age of first chest symptoms
1
F, 68
2
2
F. 48
Not available
Age b/ectasis diagnosed and method
Smoker
Clubbing
66 Sputum. CXR. chest crackles
Yes
Yes
19
No
No
Yes
Yes
No
No
No
No
Bronchogram 3
M.83
48
4
F. 54
3
5
F. 65
47
49
Sputum, CXR. chest crackles 20 Bronchogram 63 Sputum, CXR, chest crackles
CXR/ bronchogram
FEV, (1)
FVC (1)
FER (%)
RLZ shadowing
0.65
1.80
33
RLZ Shadowing bilateral tubular B'ectasis Bilateral LZ shadowing
2.60
3.10
84
1.75
2.20
75
B'ectasis left lung + RLL Bilateral mid + lower zone shadowing
0.55
1.71
32
2.24
2.85
79
CXR. chest radiograph; FEV,. forced expiratory volume in one second: FVC. forced vital capacity: FER. forced expiratory ratio
(FEWVC %).
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Birmingham on September 1, 2015
Smoking did not appear to be a significant factor; only two patients with bronchiectasis had ever smoked. All patients had characteristic coarse basal crackles, but only two had finger nail clubbing. Spirometry was abnormal in all cases, but there was no consistent pattern (Table II). All four patients had a symmetrical peripheral polyarthropathy affecting the small joints of the hands. Only two patients had rheumatoid nodules.
SOLANKI AND NEVILLE: BRONCHIECTASIS AND RHEUMATOID DISEASE
REFERENCES
1 Turner-Warwick M, Courtney-Evans R. Pulmonary manifestations of rheumatoid disease. Clin Rheum Dis 1977;3:549-64. 2. Kuhns TG, Joplin RJ. Convalescent care in chronic arthritis. N EnglJ Med 1936;215:268-72. 3. Baggenstoss AH, Rosenberg EF. Visceral lesions associated with chronic infectious (rheumatoid) arthritis. Arch Pathol 1943;35:503-16. 4. Bennett GA. Comparison of the pathology of rheumatic fever and rheumatoid arthritis. Ann Intern Med 1943;19:111-13. 5. Fingerman DL, Andrus FC. Visceral lesions associated with rheumatoid disease. Ann Rheum Dis 1943 ;3:168-81. 6. Brannan HM, Good CA, Divertie MB, Baggenstoss AH. Pulmonary disease associated with rheumatoid arthritis. JAMA 1964;189:914-18. 7. Aronoff A, Bywaters EGL, Fearnley GR. Lung
lesions in rheumatoid arthritis. Br Med J 1955;2:228-32. 8. Walker WC. The lung in rheumatoid arthritis. MD thesis. University of Edinburgh, 1966. 9. Horler AR, Thompson M. The pleural and pulmonary complications of rheumatoid arthritis. Ann Intern Med 1959;51:1179-203. 10. Cruickshank B. Interstitial pneumonia and its consequences in rheumatoid disease. Br J Dis Chest 1959;53:226-36. 11. Patterson CD, Harville WE, Pierce JA. Rheumatoid lung disease. Ann Intern Med 1965;62:685-97. 12. Thompson M. Rheumatoid arthritis. In: Reports on rheumatic diseases. 2nd ed. London: ARC, 1977: 6-10. 13. Wynn-Williams N. Bronchiectasis: a study centred on Bedford and its environs. Br Med J 1953;l:1194-9. 14. Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987, revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315-24. 15. Lewis Faning E. Report on an enquiry into the aetiological factors associated with rheumatoid arthritis. Ann Rheum 1950;D9:(suppl). 16. Ebringer A, Khalafpour S, Wilson C. Rheumatoid arthritis and Proteus: a possible aetiological association. Rheumatollnt 1989;9:223-8. 17. Schidlow DV, Goldsmith DP, Palmer J, Huang NN. Arthritis in cystic fibrosis. Arch Dis Child 1984;59:377-9. 18. Hilton AM, Doyle L. Immunological abnormalities in bronchiectasis with chronic bronchial suppuration. Br J Dis Chest 1978;72:207-16. 19. Stack BH, Grant IWB. Rheumatoid interstitial lung disease. Br J Dis Chest 1965,59:202-11. 20. Miall WE. Rheumatoid arthritis in males. Epidemiological study of a Welsh mining community. Ann Rheum Dis 1955; 14:150-8.
ANNOUNCEMENT SECOND JENNER INTERNATIONAL GLYCOIMMUNOLOGY MEETING The Second Jenner International Glycoimmunology Meeting will be held at St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE on the 1st and 2nd November 1992. Further details are available from: Susan Henderson, Academic Rheumatology Unit, Division of Immunology, St George's Hospital Medical School, Cranmer Terrace, London SW170RE. Tel: 0816729944 ext 55795; Fax: 081 784 2649.
Downloaded from http://rheumatology.oxfordjournals.org/ at University of Birmingham on September 1, 2015
Previously, the association between rheumatoid disease and bronchiectasis had been discounted on the argument that pulmonary tuberculosis was commoner in patients with rheumatoid disease [19,20] and that the bronchiectasis was related to tuberculosis. There was no historical or radiographic evidence of previous tuberculosis in the present study, all cases having basal bronchiectasis. In the present study, the frequency of bronchiectasis in rheumatoid patients was similar to that of the commonly accepted, though rare, association between pulmonary fibrosis and rheumatoid arthritis. We therefore suggest that this is a real, rather than a spurious, association and that bronchiectasis ought still to be considered a relatively common pleuropulmonary association of rheumatoid disease in the 1990s.
693
