Objective: To determine whether simple diagnostic methods can yield relevant disease information in patients with rheumatoid arthritis (RA). Methods: Patients with RA were randomly selected for inclusion in a cross-sectional study involving clinical evaluation of pulmonary function, including pulse oximetry (determination of SpO2, at rest), chest X-ray, and spirometry. Results: A total of 246 RA patients underwent complete assessments. Half of the patients in our sample reported a history of smoking. Spirometry was abnormal in 30% of the patients; the chest X-ray was abnormal in 45%; and the SpO2 was abnormal in 13%. Normal chest X-ray, spirometry, and SpO2 were observed simultaneously in only 41% of the RA patients. A history of smoking was associated with abnormal spirometry findings, including evidence of obstructive or restrictive lung disease, and with abnormal chest X-ray findings, as well as with an interstitial pattern on the chest X-ray. Comparing the patients in whom all test results were normal (n = 101) with those in whom abnormal test results were obtained (n = 145), we found a statistically significant difference between the two groups, in terms of age and smoking status. Notably, there were signs of airway disease in nearly half of the patients with minimal or no history of tobacco smoke exposure. Conclusions: Pulmonary involvement in RA can be identified through the use of a combination of diagnostic methods that are simple, safe, and inexpensive. Our results lead us to suggest that RA patients with signs of lung involvement should be screened for lung abnormalities, even if presenting with no respiratory symptoms.

Keywords: Arthritis, rheumatoid; Lung diseases, interstitial; Spirometry; Radiography, thoracic; Airway ob-struction.

Rheumatoid arthritis (RA) is an autoimmune inflammatory and heterogeneous disease that affects several systems, especially the joints. Among the extra-articular manifestations of RA, pleuropulmonary involvement occurs frequently, with different presentations, potentially in all anatomic thoracic compartments, and may determine high morbidity and mortality. The most common pleuropulmonary manifestations in patients with RA include interstitial lung disease (ILD), pleural disease, pulmonary arterial hypertension, rheumatoid lung nodules, airway disease (bronchiectasis and bronchiolitis), and lymphadenopathy. Pulmonary hypertension and ILD are the manifestations with the greatest negative impact in prognosis. HRCT of the chest is essential in the evaluation of patients with RA with respiratory symptoms, especially those with higher risk factors for ILD, such as male gender, smoking, older age, high levels of rheumatoid factor, or positive anti-cyclic citrullinated peptide antibody results. Additionally, other etiologies that may determine tomographic pleuropulmonary manifestations in patients with RA are infections, neoplasms, and drug-induced lung disease. In these scenarios, clinical presentation is heterogeneous, varying from being asymptomatic to having progressive respiratory failure. Knowledge on the potential etiologies causing tomographic pleuropulmonary manifestations in patients with RA coupled with proper clinical reasoning is crucial to diagnose and treat these patients.

Keywords: Lung diseases, interstitial; Lung diseases; Pleural diseases; Pulmonary arterial hypertension; Arthritis, rheumatoid; Tomography.

Objective: To correlate tomographic findings with pulmonary function findings, as well as to compare chest X-ray findings with high-resolution computed tomography (HRCT) findings, in patients with silicosis. Methods: A cross-sectional study was conducted in 44 non-smoking patients without a history of tuberculosis. Chest X-ray findings were classified according to the International Labour Organization recommendations. Using a semiquantitative system, the following HRCT findings were measured: the full extent of pulmonary involvement; parenchymal opacities; and emphysema. Spirometry and forced oscillation were performed. Pulmonary volumes were evaluated using the helium dilution method, and diffusing capacity of the lung for carbon monoxide was assessed. Results: Of the 44 patients studied, 41 were male. The mean age was 48.4 years. There were 4 patients who were classified as category 0 based on X-ray findings and as category 1 based on HRCT findings. Using HRCT scans, we identified progressive massive fibrosis in 33 patients, compared with only 23 patients when X-rays were used. Opacity score was found to correlate most closely with airflow, DLCO and compliance. Emphysema score correlated inversely with volume, DLCO and airflow. In this sample of patients presenting a predominance of large opacities (75% of the individuals), the deterioration of pulmonary function was associated with the extent of structural changes. Conclusions: In the early detection of silicosis and the identification of progressive massive fibrosis, HRCT scans are superior to X-rays.

Keywords: Silicosis; Occupational diseases; Tomography, x-ray computed; Respiratory function tests.

Since the beginning of the use of anti-TNF in the treatment of rheumatoid arthritis and other inflammatory diseases, cases of pulmonary tuberculosis and extrapulmonary tuberculosis have been reported in patients receiving such treatment. In most cases, the disease develops by the time the patient has received the sixth infusion. Every patient should be evaluated for latent tuberculosis infection prior to the use of a TNF inhibitor. However, the diagnosis of latent tuberculosis infection is a challenge. The tuberculin test, which was the only test available to detect latent tuberculosis infection for nearly a century, presents a number of limitations. Tests based on the detection of the in-vitro production of IFN-γ by mononuclear cells activated by specific antigens appear to be more accurate and have been studied in patients with rheumatoid arthritis.

Keywords: Tuberculosis, pulmonary; Arthritis, rheumatoid; Tumor necrosis factor-alpha; Infection.

The use of immunobiological agents for the treatment of autoimmune diseases is increasing in medical practice. Anti-TNF therapies have been increasingly used in refractory autoimmune diseases, especially rheumatoid arthritis, with promising results. However, the use of such therapies has been associated with an increased risk of developing other autoimmune diseases. In addition, the use of anti-TNF agents can cause pulmonary complications, such as reactivation of mycobacterial and fungal infections, as well as sarcoidosis and other interstitial lung diseases (ILDs). There is evidence of an association between ILD and the use of anti-TNF agents, etanercept and infliximab in particular. Adalimumab is the newest drug in this class, and some authors have suggested that its use might induce or exacerbate preexisting ILDs. In this study, we report the first case of acute ILD secondary to the use of adalimumab in Brazil, in a patient with rheumatoid arthritis and without a history of ILD.

Keywords: Lung diseases, interstitial; Arthritis, rheumatoid; Antirheumatic agents; Antibodies, monoclonal, humanized/adverse effects.

Objective: To assess the risk factors for interstitial lung disease (ILD) in patients with rheumatoid arthritis (RA) and to evaluate the association of ILD with the use of methotrexate as well as with joint disease activity. Methods: A retrospective, cross-sectional study conducted between March and December 2019 at a tertiary healthcare center, in a follow-up of RA patients who had undergone pulmonary function tests (PFT) and chest computed tomography. We evaluated the tomographic characteristics, such as the presence of ILD and its extension, as well as joint disease activity. Functional measurements, such as forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO), were also assessed. After this, a multivariate logistic regression analysis was applied in order to identify risk factors associated with ILD. Results: We evaluated 1.233 patients, of which 134 were eligible for this study. The majority were female (89.6%), with a mean age of 61 years old and with a positive rheumatoid factor (86.2%). RA-associated ILD (RA-ILD) was detected in 49 patients (36.6%). We found an association of RA-ILD with age == 62 year, male sex, smoking history and fine crackles in lung auscultation and a decreased DLCO. The indicators of being aged = 62 years old and having moderate or high RA disease activity were both independent factors associated with RA-ILD, with an odds ratio of 4.36 and 3.03, respectively. The use of methotrexate was not associated with a higher prevalence of ILD. Conclusion: Age and RA disease activity are important risk factors associated with RA-ILD. Methotrexate was not associated with the development of RA-ILD in the present study.

Keywords: Rheumatoid arthritis; Interstitial lung disease; Rheumatoid arthritis- associated interstitial lung disease.

Background: Pulmonary involvement is common in leptospirosis and usually characterized by hemoptysis, dyspnea and diffuse bilateral infiltrates in chest X-rays. Such findings may be compatible with alveolar hemorrhage, already described by some authors both in autopsies and bronchoalveolar lavage (BAL). Objective: To evaluate the presence of alveolar hemorrhage, diagnosed through BAL, in bearers of leptospirosis patients with pulmonary involvement emphasizing the method's importance for early detection of this complication. Method: Seven patients with leptospirosis were submitted to BAL. All presented respiratory symptoms and/or infiltrates in the chest X-rays and/or hypoxemia. Alveolar hemorrhage was defined by the following findings in BAL: percentage of siderophages e"20% and/or Golde score >100 and/or hemorrhagic fluid. Culture and direct tests for leptospirosis were performed in BAL. Diagnosis of disease was confirmed by microscopy serum agglutination. Results: The aspect of the bronchoscopy was normal in five patients, showed blood in the bronchial tree in one case and inflammatory manifestations in another. The BAL aspect was hemorrhagic for all patients portraying alveolar hemorrhage. Culture and direct tests were negative for Leptospiras in the BAL. Conclusions: Leptospirosis must be taken into account in the differential diagnosis of alveolar hemorrhage. The BAL was confirmed as an efficient method for detection of alveolar hemorrhage in leptospirosis, to recommend immediate therapy for the purpose of preventing its evolution to massive hemoptysis and respiratory failure.

Keywords: Leptospirosis. Bronchoalveolar lavage fluid. Radiography, thoracic.

Sarcoidosis is a multisystem inflammatory disorder of unknown cause. It most commonly affects the pulmonary system but can also affect the musculoskeletal system, albeit less frequently. In patients with sarcoidosis, rheumatic involvement is polymorphic. It can be the presenting symptom of the disease or can appear during its progression. Articular involvement is dominated by nonspecific arthralgia, polyarthritis, and Löfgren's syndrome, which is defined as the presence of lung adenopathy, arthralgia (or arthritis), and erythema nodosum. Skeletal manifestations, especially dactylitis, appear mainly as complications of chronic, multiorgan sarcoidosis. Muscle involvement in sarcoidosis is rare and usually asymptomatic. The diagnosis of rheumatic sarcoidosis is based on X-ray findings and magnetic resonance imaging findings, although the definitive diagnosis is made by anatomopathological study of biopsy samples. Musculoskeletal involvement in sarcoidosis is generally relieved with nonsteroidal anti-inflammatory drugs or corticosteroids. In corticosteroid-resistant or -dependent forms of the disease, immunosuppressive therapy, such as treatment with methotrexate or anti-TNF-, is employed. The aim of this review was to present an overview of the various types of osteoarticular and muscle involvement in sarcoidosis, focusing on their diagnosis and management.

Keywords: Sarcoidosis; Joints; Muscles; Bone and Bones.

Objective: Pulmonary disease in cystic fibrosis (CF) is characterised by recurrent episodes of pulmonary exacerbations (PExs), with acute and long-term declines in lung function (FEV1). The study sought to determine whether routine spirometry increases the frequency of PEx diagnosis, resulting in benefits to long-term pulmonary function. Methods: CF patients in the 5- to 18-year age bracket were followed for 1 year, during which they underwent spirometry before every medical visit. The main variables were the frequency of PEx diagnosis and use of antibiotics; the use of spirometry as a criterion for PEx diagnosis (a decline = 10% in baseline FEV1); and median percent predicted FEV1 over time. The data were compared with those for the previous 24-month period, when spirometry was performed electively every 6 months. Results: The study included 80 CF patients. PExs were diagnosed in 27.5% of the visits, with a mean frequency of 1.44 PExs per patient/year in 2014 vs. 0.88 PExs per patient/year in 2012 (p = 0.0001) and 1.15 PExs per patient/year in 2013 (p = 0.05). FEV1 was used as a diagnostic feature in 83.5% of PExs. In 21.9% of PExs, the decision to initiate antibiotics was solely based on an acute decline in FEV1. The median percent predicted FEV1 during the follow-up year was 85.7%, being 78.5% in 2013 and 76.8% in 2012 (p > 0.05). The median percent predicted FEV1 remained above 80% during the two years after the study. Conclusions: Routine spirometry is associated with higher rates of diagnosis and treatment of PExs, possibly impacting long-term pulmonary function.

Keywords: Cystic fibrosis; Respiratory function tests; Respiratory tract infections; Spirometry.

Background: Obesity can effect the thorax, diphragm and abdominal muscles, thereby resulting in altered respiratory function. Objective: To evaluate the effects of obesity and to determine whether body mass index (BMI) and waist circumference correlate with spirometry values in obese individuals. Method: We studied 96 non-smokers of both sexes, 48 suffering from class I and class II obesity and ranging in age rom 18 to 75. All participants presented a BMI between 30 kg/m2 and 40 kg/m2 and none had a history of morbidity. Spirometry was performed, and waist circumferences were measured. Results: No significant differences were found between the spirometric values of men with class I or II obesity and those of non-obese men. In obese women, forced vital capacity and forced expiratory volume in one second (FEV1) were significantly lower than in women who were not obese. Obese individuals of both sexes presented significantly lower expiratory reserve volume (ERV) than did non-obese individuals. Although inspiratory capacity was greater in obese men and women, the difference was significant only for the men. In obese men, there was a significant negative correlation, not seen in the women, between waist circumference and FEV1. Conclusion: Pulmonary function is altered in women suffering from class I and II obesity. In obese men, although pulmonary function is unaffected by BMI, we observed a significant negative correlation between BMI and ERV. We can conclude that pulmonary function is influenced by waist circumference in men suffering from class I and II obesity.

Keywords: Respiratory function tests. Spirometry. Body mass index. Obesity.

Two cases of complete bronchial rupture and one case of tracheobronchial rupture by blunt chest trauma were treated at the Thoracic Surgical and Respiratory Endoscopy Department of the Hospital Universitário Cajuru in a period of 2 years. The surgical technique used was end-to-end anastomosis with interrupt absorbable suture after either resection of the stenotic edges or debridement of the lacerated edges. All three patients have had good recovery. The mean period to remove the chest tubes was 3.6 days, and the mean period of discharge from the Thoracic Surgical Department was 5.6 days. The follow-up was made using chest X-ray (PA and lateral projections), lung function tests, and bronchoscopy.

Keywords: Tracheobronchial rupture. Blunt chest trauma. Evaluation. Treatment.

Objective: Behcet's syndrome, or Behcet's disease (BD), is a multisystem pathology, and survival is related to pulmonary involvement. However, it appears that different treatments correlate with different prognoses. The aim of this study was to evaluate clinical and tomographic evolution, as well as the survival, of patients with BD-related pulmonary involvement. Methods: A retrospective review of our experience with pulmonary manifestations in patients with BD treated at our institution between January 1, 1988 and April 30, 2006. The clinical, radiological, treatment and survival data were obtained from medical charts. Results: We identified 9 patients with BD-related pulmonary involvement. The mean age was 34 ± 11.5 years, and 7 of the patients were male. The radiological findings were as follows: pulmonary artery aneurysm (PAA) in 8 patients; pulmonary embolism in 3 (translating to an incidence of 5.11 cases/100 patient-years); alveolar hemorrhage in one; and pulmonary hypertension in one. The treatment consisted of immunosuppression with prednisone plus chlorambucil (or cyclophosphamide or mycophenolate mofetil) in all patients, with partial or complete resolution of the PAAs. One patient with a PAA and pulmonary hypertension also received sildenafil and warfarin, with good clinical and tomographic response (the first report in the English literature). In our sample, the mean duration of the follow-up period was 6.52 years. The three-year survival rate was 88.8%, as was the five-year survival rate. Conclusions: Patients with BD-related pulmonary involvement can present good survival with immunosuppressive therapy, and BD should be borne in mind as a possible cause of pulmonary hypertension and alveolar hemorrhage.

Keywords: Behcet Syndrome; Lung diseases, interstitial; Pulmonary circulation; Hypertension, pulmonary; Pulmonary embolism; Alveolar.

Objective: To evaluate the accuracy of bacteriological methods and of polymerase chain reaction (with primers specific for IS6110 of the Mycobacterium tuberculosis complex) in testing sputum samples from indigenous (Amerindian) and non-indigenous patients. Methods: A total of 214 sputum samples (154 from indigenous patients and 60 from non-indigenous patients) were analyzed in order to determine the accuracy of smear microscopy (direct and concentrated versions) for acid-fast bacilli, culture, and polymerase chain reaction. Results: Both microscopy methods presented low sensitivity in comparison with culture and polymerase chain reaction. Specificity ranged from 91% to 100%, the concentrated acid-fast smear technique being the least specific. Nontuberculous mycobacteria were isolated three times more frequently in samples from indigenous patients than in those from non-indigenous patients. False-positive and false-negative polymerase chain reaction results were more common in the indigenous population. Conclusion: Positivity and isolation of nontuberculous mycobacteria in the acid-fast smear in conjunction with polymerase chain reaction positivity raise the following hypotheses: nontuberculous mycobacteria species with DNA regions homologous to, or even still possessing, the M. tuberculosis IS6110 exist in the Amazon; colonization of the oropharynx or of a tuberculous lesion accelerates the growth of the nontuberculous mycobacteria present in the sputum samples, making it impossible to isolate M. tuberculosis; A history of tuberculosis results in positivity for M. tuberculosis DNA. The absence of bacteriological positivity in the presence of polymerase chain reaction positivity raises questions regarding the inherent technical characteristics of the bacteriological methods or regarding patient history of tuberculosis.

Keywords: Tuberculosis, pulmonary/diagnosis; Mycobacterium tuberculosis, Polymerase chain reaction/methods; Indians, south american