Bronchiectasis in rheumatoid arthritis: report of four cases and a review of the literature--implications for management with biologic response modifiers.

OBJECTIVE

To describe patients with rheumatoid arthritis (RA) who subsequently developed bronchiectasis (BR) and to review the literature on biologic response modifiers (BRM) in relation to infectious complications in the management of these patients.

METHODS

We describe 4 patients with RA who were diagnosed with BR out of a cohort of 170 patients. We then performed a comprehensive review of the English language literature on the major clinical trials for RA that involved the BRMs etanercept, infliximab, anakinra, and adalimumab. We focused on inclusion/exclusion criteria involving pulmonary disease and infectious complications in these trials.

RESULTS

Of the 4 patients we describe, all developed BR after the diagnosis of RA was established, had positive cyclic citrullinated peptide antibodies, had extra-articular manifestations, and had clinical courses complicated by pneumonia. Management strategies were influenced by these factors in all of the patients described. Of the 16 clinical trials on BRMs reviewed, few studies mentioned BR as an exclusion criteria or reported pneumonia as a specific infectious complication.

CONCLUSIONS

BR may be considered as an extra-articular pulmonary manifestation of RA. The infectious complications associated with BR in these patients underscore the management challenge, especially in choosing whether or not to treat with BRMs. Further studies are needed to analyze the infectious complications in RA trials with BRMs, specifically, to assess the risk of patients with BR. Risk stratification in these patients may require screening them for the presence of underlying BR.