Clinical analysis of relapsing polychondritis with airway involvement

Early Diagnosis of Relapsing Polychondritis With Airway Involvement: A Case Report

Relapsing polychondritis (RP) is a rare systemic immune-mediated disease that causes recurrent inflammation of cartilaginous tissues. Airway involvement is a significant prognostic factor; however, diagnosis is often delayed because of nonspecific symptoms. We report the case of a 38-year-old woman who presented with pharyngeal discomfort, cough, and chest pain. Initial tests revealed elevated inflammatory markers and anemia. A chest CT scan showed soft tissue enhancement around the costal cartilage and thickening of the tracheal and bronchial walls. Bronchoscopy demonstrated extensive inflammation from the larynx to the main bronchi, with approximately 90% narrowing of the left bronchus during exhalation, suggestive of tracheomalacia. Based on clinical findings, imaging, bronchoscopy, and serological tests, a diagnosis of RP was made, fulfilling McAdam's and Damiani's criteria. Although pulmonary function tests continued to show obstructive ventilatory impairment, treatment withcorticosteroids (0.6 mg/kg prednisolone) and methotrexate resulted in rapid improvement in inflammatory markers and imaging findings. This case highlights the importance of early bronchoscopy in assessing airway involvement in RP, even when respiratory symptoms are mild, and emphasizes the need to balance the diagnostic benefits against potential risks, particularly in those with reduced forced vital capacity. Early diagnosis and timely intervention, including consideration of biologics, may prevent progression to severe airway compromise.

18F-FAPI versus 18F-FDG PET/CT in the Diagnosis of Relapsing Polychondritis

Relapsing polychondritis (RP) is a rare immune-mediated systemic inflammatory disease with diverse clinical manifestations. Independent involvement of the respiratory system in RP is uncommon. In the event of respiratory involvement as the initial airway-only manifestation, the diagnosis of RP is challenging and might be delayed, and patients with respiratory involvement exhibit a poor prognosis. However, no specific diagnostic method is currently available for RP with respiratory system involvement as the main clinical manifestation. We present a 49-year-old female with the complaint of chronic dry cough accompanied by shortness of breath after exercise that has persisted for over a year. The patient was treated using corticosteroids. The patient's symptoms improved rapidly with the administration of 5 days of methylprednisolone sodium succinate at a dose of 40 mg/day. The treatment was then switched to methylprednisolone tablets at a dose of 40 mg/day, and the dosage was reduced by 4 mg every week until the cessation of therapy. Meanwhile, oral cyclophosphamide tablets were administered once every day at a dose of 100 mg each time. After 1 month of treatment, the symptoms of cough disappeared, the modified british medical research council (mMRC) grade dropped from 4 to 2, and the COPD assessment test (CAT) score dropped from 30 to 17. Repeated CT of the chest revealed that the tracheal wall thickening had alleviated. No recurrence was revealed in the follow-up visit 12 months after drug withdrawal. The patient underwent 18F-FDG PET/CT examination before hormone and immunosuppressive therapy, and 18F-FAPI PET/CT examination was performed 5 days later. The 18F-FDG PET/CT method revealed slight thickening of the local wall of the trachea and the left and right main bronchus, with no increase in the FDG metabolism, and no abnormalities in the rest of the cartilage. 18F-FAPI PET-CT imaging showed increased FAPI uptake in various parts of the body, including trachea and bronchus. The present study reports that compared to 18F-FDG PET/CT, the 18F-FAPI PET/CT revealed more lesions and provided a better image contrast, suggesting the latter as a suitable diagnostic method for RP, which could assist in improving the clinical management of RP patients.

Diagnostic Challenges and Management of Relapsing Polychondritis with Large-Airway Involvement: A Case Series and Literature Review

OBJECTIVES

Our aim was to investigate the diagnostic challenges and management of relapsing polychondritis (RP) with airway involvement, highlighting the need for accurate diagnosis and effective intervention to prevent severe complications.

METHODS

In this retrospective study, medical records from January 2011 through June 2024 at a single tertiary-care institution were reviewed. This study was approved by the institutional review board. A total of 34 patients were diagnosed with RP, among whom 4 presented with significant airway complications. This study focused on these four patients, detailing their clinical presentations, diagnostic processes, and outcomes following various interventions.

RESULTS

All patients were initially misdiagnosed with asthma and later developed severe airway issues necessitating interventions such as tracheotomy and endotracheal intubation. Diagnostic imaging, microlaryngoscopy and bronchoscopy (MLB) were crucial for identifying subglottic stenosis and other airway alterations. Treatments included high-dose steroids, rituximab, and surgical interventions such as balloon dilation and tracheostomy. Only one patient could be decannulated; the other three remained dependent on tracheostomy and experienced significant complications due to emergency medical interventions.

CONCLUSIONS

RP can manifest with nonspecific respiratory symptoms similar to asthma, which may delay correct diagnosis and appropriate treatment, leading to critical airway complications. The early, precise identification of RP, particularly with airway involvement, is vital. MLB and dynamic expiratory CT scans play significant roles in clinical diagnosis and management. A multidisciplinary approach involving otolaryngologists, rheumatologists, and pulmonologists is essential for optimizing patient outcomes and minimizing complications.

Relapsing polychondritis: clinical updates and new differential diagnoses

Relapsing polychondritis is a rare inflammatory disease characterized by recurrent inflammation of cartilaginous structures, mainly of the ears, nose and respiratory tract, with a broad spectrum of accompanying systemic features. Despite its rarity, prompt recognition and accurate diagnosis of relapsing polychondritis is crucial for appropriate management and optimal outcomes. Our understanding of relapsing polychondritis has changed markedly in the past couple of years with the identification of three distinct patient clusters that have different clinical manifestations and prognostic outcomes. With the progress of pangenomic sequencing and the discovery of new somatic and monogenic autoinflammatory diseases, new differential diagnoses have emerged, notably the vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic (VEXAS) syndrome, autoinflammatory diseases and immune checkpoint inhibitor-related adverse events. In this Review, we present a detailed update of the newly identified clusters and highlight red flags that should raise suspicion of these alternative diagnoses. The identification of these different clusters and mimickers has a direct impact on the management, follow-up and prognosis of patients with relapsing polychondritis and autoinflammatory syndromes.

Imaging features and clinical value of 18F-FDG PET/CT for predicting airway involvement in patients with relapsing polychondritis

BACKGROUND

The clinical value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in assessing relapsing polychondritis (RP) with airway involvement remains controversial. This study aimed to investigate PET/CT features of RP with airway involvement and explore its clinical value in predicting disease pattern, severity and prognosis.

METHODS

RP patients with airway involvement who underwent PET/CT from January 2010 to July 2022 were retrospectively reviewed. PET/CT features were analyzed both visually and semiquantitatively with the maximum standardized uptake value (SUVmax) and total lesion glycolysis (TLG). Patterns of airway involvement on PET were summarized. Correlations of SUVmax and TLG of the airway were made with spirometric indicators and serological inflammatory markers (CRP and ESR). In addition, long-term follow-up was conducted through questionnaires in regard to symptom control, subjective feeling, pulmonary function, and quality of life.

RESULTS

Fifty-two cases were finally included. 18F-FDG PET showed FDG-avid lesions with increased FDG uptake in the airway among 94.2% of the patients. Three patterns (focal, multifocal and diffuse patterns) were identified. TLG of the whole airway was lower in patients with previous therapy (p = 0.046). Bronchoscopy was more sensitive in detecting tracheal abnormalities (90.7% vs.53.5%, p = 0.039) but less sensitive for peripheral airway lesions (65.1% vs. 79.1%, p = 0.046) compared with PET. SUVmax and TLG of the airway positively correlated with spirometry indicators (FEV1%pred, FEV1/FVC, MEF 50%pred, etc.) and serological inflammatory markers. Five patients died during the follow-up, with two deaths related to airway problems. Higher FDG uptake predicted worse subjective feeling, but not with symptom control or pulmonary function.

CONCLUSION

PET/CT is a valuable tool for RP with airway involvement, particularly in assessing peripheral airway lesions, and PET/CT related parameters are significantly associated with disease patterns, severity, and long-term outcomes.

Relapsing polychondritis causing breathlessness: Two case reports

BACKGROUND

Relapsing polychondritis is a rare multisystem autoimmune disease that mainly involves systemic cartilage and proteoglycan-rich tissues. If the larynx and trachea are involved, the patient’s condition deteriorates rapidly. When relapsing polychondritis becomes more advanced, the airways collapse and treatment is difficult, rendering a poor prognosis. Therefore, the diagnosis method, treatment strategy and prognosis of relapsing polychondritis with larynx and trachea involvement need to be elucidated to improve clinicians’ awareness of the disease.

CASE SUMMARY

A man and a woman were admitted because of breathlessness. Relapsing polychondritis was diagnosed after a series of accessory examinations. They were both treated with glucocorticoids and immunosuppressants, and underwent tracheotomy as their breathing difficulties could not be relieved by the medication.

CONCLUSION

The two cases highlight the importance of the timely diagnosis, full evaluation and initiating individualized treatment of relapsing polychondritis with larynx and trachea involvement. Laryngoscopy, bronchoscopy and pathological examination are helpful in diagnosis of this disease.