Caspian J Intern Med 2017; 8(3):220-222 DOI: 10.22088/cjim.8.3.220 Case Report Ines Mahmoud (MD) 1 Aicha Ben Tekaya (MD) 1* Rawdha Tekaya (MD) 1 Olfa Saidane (MD) 1 Leila Gafsi (MD) 1 Mathilde Benhammou (MD) 2 Fautrel Bruno (MD) 2 Leila Abdelmoula (MD) 1 1. Department of Rheumatology, Charles Nicolle, Tunis, Tunisia. 2. Department of Rheumatology, Pitié Salpetrière Hospital, Paris, France. * Correspondence: Aicha Ben Tekaya, Department of Rheumatology Charles Nicolle, Tunis, Tunisia. E-mail: aichabentekaya@gmail.com Tel: 0021 697850485 Fax: 0021 671571055 Received: 7 April 2016 Revised: 20 June 2016 Accepted: 31 July 2016 Pulmonary nodules in a patient with rheumatoid arthritis: Which diagnostic approach is the most appropriate? Abstract Background: Pulmonary nodular excavation should firstly evoke tuberculosis or necrosis broncho-pulmonary tumor, particularly: epidermoid carcinoma. The case discussed here illustrated these difficulties in patients with rheumatoid arthritis (RA). Case Presentation: A 63-year-old woman was presented with a-three-year history of RA and a recent discovery of an excavated pulmonary nodule. Initial investigations focused on a rheumatoid origin. The evolution of the disease was worrisome and surgical exploration was deemed mandatory. The result was the discovery of a nodule of a malignant nature. Conclusion: In this paper, we discussed the excavation of the pulmonary nodule, its diagnoses and management of the difficulties we encountered. Keywords: Pulmonary nodule, Rheumatoid arthritis, Epidermoid carcinoma, Tumor cavitation, Computed tomography. Citation: Mahmoud I, Tekaya AB, Tekaya R, et al. Pulmonary nodules in a patient with rheumatoid arthritis: Which diagnostic approach is the most appropriate? Caspian J Intern Med 2017; 8(3): 220-222. R arely, epidermoid carcinoma can have a nodular appearance in x-ray imaging. In 10% of cases, the excavation shows thickened walls and a nodular internal surface (1). Yet, pulmonary nodular excavation should firstly evoke tuberculosis or necrosis broncho- pulmonary tumor, particularly: epidermoid carcinoma (2). Some diagnostic difficulties may arise despite the current sophisticated means of investigations. The case discussed here illustrated these difficulties in patients with RA. Case Presentation A 63-year-old woman was presented with a-three-year history of rheumatoid arthritis (RA) and a recent discovery of a pulmonary nodule. Her RA is erosive, sero-positive (RF and anti-CCP) and was never treated with a disease modifying anti-rheumatic drug (DMARD). Moreover, she smoked for 30 years and stopped 12 years ago. As part of the pre-therapeutic checkup of the RA, chest radiography was done and showed a suspect nodule. Chest computed tomography was then performed in July, 2009. This CT revealed a pulmonary nodule measuring 3 cm across the 3 lobes of the right lung and an axillary adenopathy with no suspect aspect of malignancy. Several diagnoses were considered including: infectious origin, cancer, rheumatoid nodule and so on. A PET scan was then performed. A hypermetabolism of the pulmonary nodule (SUV max to 4.2) associated with hypermetabolism of two contralateral axillary adenopathies (SUV:1.7), having no suspect aspect of malignancy, were found (figure1). The bronchoscopy did not show any abnormalities. Abdominal CT was normal. A biopsy was conducted in August 2009 and was negative. Usual causes of infections were eliminated. However, a therapeutic test with probabilistic broad spectrum antibiotherapy with cotrimoxazole was started for 3 weeks, with no significant impact on the nodule.