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Zamora AC, Wesselius LJ, Gotway MB, Tazelaar HD, Diaz-Arumir A, Nagaraja V. Diagnostic Approach to Interstitial Lung Diseases Associated with Connective Tissue Diseases. Semin Respir Crit Care Med 2024; 45:287-304. [PMID: 38631369 DOI: 10.1055/s-0044-1785674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Interstitial lung disorders are a group of respiratory diseases characterized by interstitial compartment infiltration, varying degrees of infiltration, and fibrosis, with or without small airway involvement. Although some are idiopathic (e.g., idiopathic pulmonary fibrosis, idiopathic interstitial pneumonias, and sarcoidosis), the great majority have an underlying etiology, such as systemic autoimmune rheumatic disease (SARD, also called Connective Tissue Diseases or CTD), inhalational exposure to organic matter, medications, and rarely, genetic disorders. This review focuses on diagnostic approaches in interstitial lung diseases associated with SARDs. To make an accurate diagnosis, a multidisciplinary, personalized approach is required, with input from various specialties, including pulmonary, rheumatology, radiology, and pathology, to reach a consensus. In a minority of patients, a definitive diagnosis cannot be established. Their clinical presentations and prognosis can be variable even within subsets of SARDs.
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Affiliation(s)
- Ana C Zamora
- Division of Pulmonary and Sleep Medicine, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Lewis J Wesselius
- Division of Pulmonary and Sleep Medicine, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Michael B Gotway
- Division of Cardiothoracic Radiology, Department of Radiology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Henry D Tazelaar
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Alejandro Diaz-Arumir
- Division of Pulmonary and Sleep Medicine, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
| | - Vivek Nagaraja
- Division of Rheumatology, Department of Medicine, Mayo Clinic Arizona, Scottsdale, Arizona
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Libra A, Colaci M, Spicuzza L, Luca G, Fischetti S, Pashalidis G, Ferrara CA, Ielo G, Sambataro D, La Rosa G, Libra F, Palmucci S, Vancheri C, Sambataro G. The Pattern and Progression of "Usual" Interstitial Pneumonia with Autoimmune Features: Comparison with Patients with Classic Interstitial Pneumonia with Autoimmune Features and Idiopathic Pulmonary Fibrosis. J Clin Med 2024; 13:369. [PMID: 38256503 PMCID: PMC10816405 DOI: 10.3390/jcm13020369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/06/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND We proposed the term "UIPAF" to define patients with Usual Interstitial Pneumonia (UIP) associated with only one domain of the classification called "Interstitial Pneumonia with Autoimmune Features" (IPAF). The objective of this study was to evaluate the clinical presentation and prognosis of UIPAF patients, compared with two cohorts, composed of IPAF and idiopathic pulmonary fibrosis (IPF) patients, respectively. METHODS The patients were enrolled as IPAF, UIPAF, or IPF based on clinical, serological, and radiological data and evaluated by a multidisciplinary team. RESULTS We enrolled 110 patients with IPF, 69 UIPAF, and 123 IPAF subjects. UIPAF patients were similar to IPAF regarding autoimmune features, except for the prevalence of Rheumatoid Factor in UIPAF and anti-SSA in IPAF. A similar proportion of the two cohorts progressed toward a specific autoimmune disease (SAD), with differences in the kind of SAD developed. The real-life management and prognosis of UIPAF patients proved to be almost identical to IPF. CONCLUSIONS UIPAF shared with IPAF similar autoimmune features, suggesting the opportunity to be considered IPAF, excluding the morphological domain by the classification. However, the real-life management and prognosis of UIPAF are similar to IPF. These data suggest a possible modification in the therapeutic management of UIPAF.
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Affiliation(s)
- Alessandro Libra
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, Policlinico “G. Rodolico-San Marco”, University of Catania, 95123 Catania, Italy; (A.L.); (L.S.); (G.L.); (S.F.); (G.P.); (C.A.F.); (G.I.); (C.V.)
| | - Michele Colaci
- Internal Medicine Unit, Department of Clinical and Experimental Medicine, Division of Rheumatology, Cannizzaro Hospital, University of Catania, 95123 Catania, Italy;
| | - Lucia Spicuzza
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, Policlinico “G. Rodolico-San Marco”, University of Catania, 95123 Catania, Italy; (A.L.); (L.S.); (G.L.); (S.F.); (G.P.); (C.A.F.); (G.I.); (C.V.)
| | - Giuliana Luca
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, Policlinico “G. Rodolico-San Marco”, University of Catania, 95123 Catania, Italy; (A.L.); (L.S.); (G.L.); (S.F.); (G.P.); (C.A.F.); (G.I.); (C.V.)
| | - Sefora Fischetti
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, Policlinico “G. Rodolico-San Marco”, University of Catania, 95123 Catania, Italy; (A.L.); (L.S.); (G.L.); (S.F.); (G.P.); (C.A.F.); (G.I.); (C.V.)
| | - Giorgio Pashalidis
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, Policlinico “G. Rodolico-San Marco”, University of Catania, 95123 Catania, Italy; (A.L.); (L.S.); (G.L.); (S.F.); (G.P.); (C.A.F.); (G.I.); (C.V.)
| | - Chiara Alfia Ferrara
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, Policlinico “G. Rodolico-San Marco”, University of Catania, 95123 Catania, Italy; (A.L.); (L.S.); (G.L.); (S.F.); (G.P.); (C.A.F.); (G.I.); (C.V.)
| | - Giuseppe Ielo
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, Policlinico “G. Rodolico-San Marco”, University of Catania, 95123 Catania, Italy; (A.L.); (L.S.); (G.L.); (S.F.); (G.P.); (C.A.F.); (G.I.); (C.V.)
| | - Domenico Sambataro
- Artroreuma s.r.l., Rheumatology Outpatient Clinic, 95030 Mascalucia (CT), Italy;
| | - Giuliana La Rosa
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico “G. Rodolico-San Marco”, 95123 Catania, Italy; (G.L.R.); (F.L.)
| | - Federica Libra
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico “G. Rodolico-San Marco”, 95123 Catania, Italy; (G.L.R.); (F.L.)
| | - Stefano Palmucci
- Department of Medical Surgical Sciences and Advanced Technologies “GF Ingrassia”, University Hospital Policlinico “G. Rodolico-San Marco”, Unità Operativa Semplice Dipartimentale di Imaging Polmonare e Tecniche Radiologiche Avanzate (UOSD IPTRA), 95123 Catania, Italy;
| | - Carlo Vancheri
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, Policlinico “G. Rodolico-San Marco”, University of Catania, 95123 Catania, Italy; (A.L.); (L.S.); (G.L.); (S.F.); (G.P.); (C.A.F.); (G.I.); (C.V.)
| | - Gianluca Sambataro
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, Policlinico “G. Rodolico-San Marco”, University of Catania, 95123 Catania, Italy; (A.L.); (L.S.); (G.L.); (S.F.); (G.P.); (C.A.F.); (G.I.); (C.V.)
- Internal Medicine Unit, Department of Clinical and Experimental Medicine, Division of Rheumatology, Cannizzaro Hospital, University of Catania, 95123 Catania, Italy;
- Artroreuma s.r.l., Rheumatology Outpatient Clinic, 95030 Mascalucia (CT), Italy;
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Joerns EK, Mills B, Makris UE, Adams TN, Bermas B. Low Rates of Reproductive Counseling Documentation in Women With Interstitial Pneumonia With Autoimmune Features. J Clin Rheumatol 2023; 29:145-150. [PMID: 36730332 PMCID: PMC10045969 DOI: 10.1097/rhu.0000000000001929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND/OBJECTIVE Women with interstitial pneumonia with autoimmune features (IPAFs), a subset of interstitial lung disease (ILD), are at risk for pregnancy complications. Family planning discussions improve pregnancy outcomes in women with ILD. The objective of this study was to evaluate the documentation of reproductive counseling in IPAF female patients of childbearing age by pulmonary and rheumatology providers at an academic medical center. METHODS We conducted a medical record review study of pulmonary and rheumatology encounters in reproductive-aged women with IPAF to evaluate documentation of family planning discussions and contraceptive use. We used nonparametric measures of association and logistic regression to evaluate the relationship between patient characteristics and the presence of reproductive counseling documentation by providers. RESULTS Thirty-one women met IPAF classification and were ≤50 years at initial ILD clinic visit. Twenty-five (81%) of these women had risk factors for adverse pregnancy outcomes. Ten women (32%) had a record of reproductive counseling during any visit with their pulmonary provider. Of the 21 patients who also saw a rheumatology provider, 12 (57%) women had a record of reproductive counseling during any visit with their rheumatology provider. No baseline characteristics were associated with odds of reproductive counseling documentation. CONCLUSIONS Neither pulmonary nor rheumatology providers consistently discussed family planning/contraceptive use with reproductive-aged women with IPAF. There was a trend for rheumatology providers to discuss reproductive issues with IPAF patients more frequently than pulmonary providers. Efforts should focus on educating providers about the need for reproductive counseling in women with IPAF of childbearing age.
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Affiliation(s)
- Elena K. Joerns
- From the Division of Rheumatic Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center
| | - Brooke Mills
- From the Division of Rheumatic Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center
| | - Una E. Makris
- From the Division of Rheumatic Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center
- Division of Rheumatic Diseases, Department of Internal Medicine, Veterans Affairs North Texas Health Care System
| | - Traci N. Adams
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Bonnie Bermas
- From the Division of Rheumatic Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center
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Functional respiratory impairment and related factors in patients with interstitial pneumonia with autoimmune features (IPAF): Multicenter study from NEREA registry. Respir Res 2023; 24:19. [PMID: 36653833 PMCID: PMC9847038 DOI: 10.1186/s12931-023-02317-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/05/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The objective of the present study is to describe the characteristics of interstitial pneumonia with autoimmune features (IPAF) patients, to assess the incidence rate of functional respiratory impairment over time and to evaluate the influence of therapeutic alternatives on the prognosis of these patients. METHODS A longitudinal observational multicenter study was performed (NEREA registry). It was carried out by a multidisciplinary team in seven Hospitals of Madrid. Patients were included from IPAF diagnosis. MAIN OUTCOME poor prognosis as functional respiratory impairment (relative decline in FVC % defined as ≥ 5% every 6 months). Covariates: therapy, sociodemographic, clinical, radiological patterns, laboratory and functional tests. STATISTICS Survival techniques were used to estimate IR per 100 patients-semester with their 95% confidence interval [CI]. The influence of covariates in prognosis were analyzed through cox multivariate regression models (hazard ratio (HR) and [CI]). RESULTS 79 IPAF were included, with a mean and a maximum follow-up of 3.17 and 12 years respectively. Along the study, 77.2% received treatment (52 glucocorticoids, 25 mycophenolate, 21 azathioprine, 15 rituximab and 11 antifibrotics). IR was 23.9 [19.9-28.8], and 50% of IPAF developed functional respiratory impairment after 16 months from its diagnosis. Multivariate analysis: usual interstitial pneumonia (UIP) had poorer prognosis compared to non-specific interstitial pneumonia (NSIP) (p = 0.001). In NSIP, positive ANA, increased the risk of poor prognosis. In UIP, glucocorticoids (HR: 0.53 [0.34-0.83]), age (HR: 1.04 [1.01-1.07]), and Ro-antibodies (HR: 0.36 [0.19-0.65]) influenced the prognosis. CONCLUSIONS IPAF have functional impairment during the first years of disease. Factors predicting deterioration differ between radiographic patterns. Our real-life study suggests the potential benefit of particular therapies in IPAF.
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van den Bosch L, Luppi F, Ferrara G, Mura M. Immunomodulatory treatment of interstitial lung disease. Ther Adv Respir Dis 2022; 16:17534666221117002. [PMID: 35938712 PMCID: PMC9364223 DOI: 10.1177/17534666221117002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF) have an array of immunomodulatory treatment options compared with IPF, due to their inflammatory component. However, there is a relative paucity of guidance on the management of this heterogeneous group of diseases. In ILDs other than IPF, immunosuppression is the cornerstone of therapy, with varying levels of evidence for different immunomodulatory agents and for each specific ILD. Classification of ILDs is important for guiding treatment decisions. Immunomodulatory agents mainly include corticosteroids, mycophenolate mofetil (MMF), azathioprine, methotrexate, cyclophosphamide and rituximab. In this review, the available evidence for single agents in the most common ILDs is first discussed. We then reviewed practical therapeutic approaches in connective tissue disease-related ILD and interstitial pneumonia with autoimmune features, scleroderma-related ILD, vasculitis and dermatomyositis with hypoxemic respiratory failure, idiopathic non-specific interstitial pneumonia, hypersensitivity pneumonitis sarcoidosis, fibrosing organizing pneumonia and eosinophilic pneumonia. The treatment of acute exacerbations of ILD is also discussed. Therapy augmentation in ILD is dictated by the recognition of progression of disease. Criteria for the evaluation of progression of disease are then discussed. Finally, specific protocol and measures to increase patients' safety are reviewed as well, including general monitoring and serologic surveillance, Pneumocystis jirovecii prophylaxis, patients' education, genetic testing for azathioprine, MMF serum levels and cyclophosphamide administration protocols. Immunomodulatory therapies are largely successful in the management of ILDs and can be safely managed with the application of specific protocols, precautions and monitoring.
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Affiliation(s)
| | - Fabrizio Luppi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Respiratory Unit, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Giovanni Ferrara
- Division of Pulmonary Medicine, University of Alberta, Edmonton, AB, Canada
| | - Marco Mura
- London Health Sciences Centre, Victoria Hospital, 800 Commissioners Road East, Room E6-203, London, ON N6A 5W9, Canada
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