Rheumatoid arthritis (RA) can impact more than just the joints. It can also impact the lungs, causing difficulty breathing and even chest pains. To learn more about how RA can affect the lungs and chest, we interviewed Dr. Jeffrey Sparks, a rheumatologist and clinical researcher at Brigham and Women's Hospital and Harvard Medical School in Boston. Dr. Sparks specializes in rheumatoid arthritis and inflammatory lung diseases.
A small percentage (4 percent to 10 percent) of people with RA are diagnosed with a condition known as interstitial lung disease or ILD. It typically appears in patients between the ages of 50 and 60. In ILD, the same autoimmune condition that causes inflammation in the joints also leads to inflammation and scarring in the lungs. ILD can lead to shortness of breath, difficulty breathing, and a dry, unproductive cough. In instances where severe scarring has built up over time — enough that treatment with corticosteroids, immunosuppressants, and oxygen therapy no longer help — a lung transplant may be required.
ILD is also associated with environmental factors like smoking or exposure to asbestos or dust from coal. While most RA patients are not smokers, Dr. Sparks strongly urges any who are smokers to stop immediately. People with RA are eight times more likely to develop ILD than someone who does not have RA.
Not all lung inflammation from RA leads to ILD, however. “There might be many other patients that have some subtle inflammation in the lung that never really caused a symptom,” Dr. Sparks said. “Some [people with RA] might progress very slowly where a chest CT [scan] today might find a little bit of inflammation, and two years down the road, it's gotten to the point where it's causing more issues.” In these instances, Dr. Sparks explained, the treatment course is developed on a case-by-case basis.
There are a host of reasons a person might experience chest pain, including heart disease, angina, or heart attack. Dr. Sparks shared that some forms of chest pain that linger for weeks or months might be due to another condition impacting people with RA. “That chest pain can sometimes be related to costochondritis, which is basically pain related to the insertion of the ribs in the cartilage, to either the back or the sternum,” he said.
People with rheumatoid arthritis are particularly prone to that sort of musculoskeletal pain, which may include inflammation of those internal joints. “There might even be a subset of patients that actually have some inflammation in those kinds of joints — as there are bones there that are connecting with each other, just like joints in the hands,” Dr. Sparks said. “But by and large, it seems to be not related to the typical inflammation that you might see in the hands and wrists of rheumatoid arthritis.”
Dr. Sparks advises anyone with chest pain — particularly new chest pain, but also any lingering chest pain — to bring it up with their doctor immediately. “There’s a really long list of things [that can cause chest pain], some of which are common and relatively not serious … and some that are serious. So you want to be evaluated to make sure that one of the serious causes isn’t missed,” Dr. Sparks said.
Dr. Sparks talked about three ways people with both RA and lung inflammation may experience flares.
“The patients with interstitial lung disease may or may not have inflammation in their joints,” Dr. Sparks said. “We do see three patterns in roughly the same proportion: Some patients have mostly flares in their joints, and their lung disease is relatively stable. Some people might have a more dominant course related to lung inflammation, and their joints are relatively stable. And then there are some patients that really flare simultaneously in their joints and their lungs.”
“That's why it's important to have a multidisciplinary approach and to work with a pulmonologist and a rheumatologist who's comfortable with treating inflammatory lung disease,” Dr. Sparks said. “The management is quite tricky, given that you're working with two different organs.”
Dr. Sparks discussed the added challenge his patients with lung disease are having during the COVID-19 outbreak. It can be hard to determine whether symptoms are coming from lung inflammation or the virus.
“Some of my patients have lung damage from rheumatic diseases,” Dr. Sparks said. “You can imagine that they're particularly susceptible to both infection and outcomes from coronavirus, but they're also more likely to have constant shortness of breath and chest pain unrelated to coronavirus. So this has been really tricky to manage, particularly virtually [via telemedicine], because these patients’ [situations] are relatively complex.”
Determining which patients to bring to the hospital for further tests can be challenging. Working in a cross-disciplinary team has been very helpful to Dr. Sparks. “I luckily have a dedicated pulmonary colleague. We've had to make some calls about patients that need to go to the emergency department to get tested or have a chest X-ray,” he said.
When patients are able to come to the clinic, “It's a pretty easy decision to order chest X-ray and have them go down the hall [for tests],” Dr. Sparks said. “It's just a testament to the different times that we live in. Even easy things like blood work and chest X-rays require a choreographed approach, and [there are] logistics about whether it's worth going down that route. It is definitely a new era.”