CTICasesRheumatoid Arthritis with Constrictive Bronchiolitis
Imaging findings
CT demonstrates mosaic attenuation with geographic areas of low attenuation in a patient with rheumatoid arthritis. Bronchial wall thickening is identified. The low attenuation areas worsen on inspiratory images as we go more inferiorly and the lungs become progressively darker with increasing air trapping. Expiratory CT confirms extensive air trapping in the lower lung zones with geographic lobular non-deflation. Minimum intensity projection images help demonstrate the pervasive air trapping. Open lung biopsy demonstrated follicular bronchiolitis and constrictive bronchiolitis with increased mural smooth muscle in terminal airways.
Key takeaways
Constrictive bronchiolitis (obliterative bronchiolitis) associated with rheumatoid arthritis produces severe obstructive lung disease with CT findings of bilateral mosaic attenuation and geographic air trapping on expiratory imaging without significant bronchiectasis or nodular disease. The combination of follicular bronchiolitis and constrictive bronchiolitis on biopsy reflects the spectrum of RA-related airway disease. Constrictive bronchiolitis is not ILD — it is an airways disease defined by concentric submucosal fibrosis narrowing the terminal airways, producing air trapping rather than the fibrosis and traction bronchiectasis of interstitial pneumonias. PFTs typically show severe airflow obstruction.
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