Interstitial Lung Disease and Other Pulmonary Manifestations in … · 2019-09-10 · Lung...

REVIEW

Interstitial Lung Disease and OtherPulmonary Manifestations in ConnectiveTissue DiseasesIsabel Mira-Avendano, MD; Andy Abril, MD; Charles D. Burger, MD;Paul F. Dellaripa, MD; Aryeh Fischer, MD; Michael B. Gotway, MD;Augustine S. Lee, MD; Joyce S. Lee, MD; Eric L. Matteson, MD, MPH;Eunhee S. Yi, MD; and Jay H. Ryu, MD

Abstract

Lung involvement in connective tissue diseases is associated with substantial morbidity and mortality,most commonly in the form of interstitial lung disease, and can occur in any of these disorders.Patterns of interstitial lung disease in patients with connective tissue disease are similar to those seenin idiopathic interstitial pneumonias, such as idiopathic pulmonary fibrosis. It may be difficult todistinguish between the 2 ailments, particularly when interstitial lung disease presents beforeextrapulmonary manifestations of the underlying connective tissue disease. There are importantclinical implications in achieving this distinction. Given the complexities inherent in the managementof these patients, a multidisciplinary evaluation is needed to optimize the diagnostic process andmanagement strategies. The aim of this article was to summarize an approach to diagnosis andmanagement based on the opinion of experts on this topic.

ª 2018 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2019;94(2):309-325

From the Division of Pul-monary, Allergy, and SleepMedicine (I.M.-A., C.D.B.,A.S.L.) and Division ofRheumatology (A.A.),Mayo Clinic, Jacksonville,FL; Division of Rheuma-tology, Brigham andWomen’s Hospital, Har-vard Medical School, Bos-ton, MA (P.F.D.);Department of Medicine,University of Colorado,Denver, Aurora, CO (A.F.,J.S.L.); Division of Cardio-thoracic Radiology, MayoClinic, Scottsdale, AZ(M.B.G.); and Center forClinical and TranslationalScience (E.L.M.), Divisionof Anatomic Pathology(E.S.Y.), and Division ofPulmonary and CriticalCare Medicine (J.H.R.),Mayo Clinic, Rochester,MN.

I nterstitial lung diseases (ILDs) comprise agroup of diffuse parenchymal infiltrativelung disorders classified according to etio-

logic, clinical, radiologic, and histopathologicfeatures. Some of the most common forms ofILD, such as idiopathic pulmonary fibrosis(IPF), are of unknown origin; however,some have identifiable causes, including envi-ronmental exposures, drugs, tobacco smoke,genetic disorders, and autoimmune diseases.The latter group includes connective tissuediseases (CTDs), which are characterized byimmune-mediated tissue injury that caninvolve the lungs.1-3

The features of CTD-related ILD (CTD-ILD) usually present in patients alreadydiagnosed as having CTD. However, ILDmay be the presenting feature, sometimesaccompanied by findings suggestive of anunderlying autoimmune process but notsufficient for a definitive CTD diagnosis.3,4

Under such circumstances, the diagnosisand clinical implications thereof often

Mayo Clin Proc. n February 2019;94(2):309-325 n https://doi.org/1www.mayoclinicproceedings.org n ª 2018 Mayo Foundation for M

Downloaded for Anonymous User (n/a) at Sint AFor personal use only. No other uses withou

remain unclear.5,6 In patients with CTDs,ILD is associated with substantial morbidityand mortality. For example, the 5-year mor-tality rate is 3-fold higher in patients withrheumatoid arthritis (RA) and sclerodermawho have ILD.7,8 However, compared withthose with idiopathic interstitial pneumonias(IIPs), patients with CTD-ILD are morelikely to respond to immunosuppressivetherapy and have a better prognosis.3,5,6,9

Because of the challenges in diagnosisand management of patients with CTD-ILDs, a multidisciplinary approach involvingrelevant specialties, including pulmonology,rheumatology, radiology, and pathology, isvital for optimal care. In November 2017, amultidisciplinary symposium on pulmonarymanifestations of CTDs took place at AmeliaIsland, Florida, organized by the Divisions ofRheumatology and Pulmonary, Allergy, andSleep Medicine of Mayo Clinic in Florida.This article summarizes the proceedings ofthis conference.

0.1016/j.mayocp.2018.09.002edical Education and Research

309

ntonius Hospital from ClinicalKey.com by Elsevier on May 14, 2019.t permission. Copyright ©2019. Elsevier Inc. All rights reserved.

http://crossmark.crossref.org/dialog/?doi=10.1016/j.mayocp.2018.09.002&domain=pdf

https://doi.org/10.1016/j.mayocp.2018.09.002

http://www.mayoclinicproceedings.org

ARTICLE HIGHLIGHTS

d Interstitial lung disease is present in approximately 40% of pa-tients with connective tissue disorders, contributing toincreased morbidity and mortality.

d Interstitial lung disease in association with connective tissuedisorder has a better prognosis than idiopathic counterparts.

d Characteristic patterns on chest computed tomography helpdistinguish the various interstitial lung disease manifestations inpatients with connective tissue disorders.

d Treatment options have expanded and may offer improvedoutcomes.

MAYO CLINIC PROCEEDINGS

310

Dow

CLINICAL APPROACH TO CTD-ILDInterstitial lung disease complicating CTDtypically, but not always, occurs after anestablished diagnosis of a CTD.1 BecauseCTD-ILDs share radiologic, physiologic,and even histopathologic features with IIPsand other ILDs, close collaboration betweenrheumatology, pulmonology, radiology, andpathology is important in achieving anappropriate diagnosis and guidingmanagement.

Dyspnea and cough are unlikely to bedifferentiating symptoms between CTD-ILDand other ILDs,10 and the clinician mustprobe for extrapulmonary symptoms with acareful systems review for clues toward anunderlying CTD. Similarly, the respiratoryexamination will be less revealing than find-ings outside the lung in helping to identifyan underlying systemic inflammatory disor-der as the basis of the patient’s ILD.

After a thorough history and physicalexamination, the pulmonary function test isinstrumental for diagnosing and trackingILD. Typically, ILDs will be characterizedby a restrictive ventilatory defect (ie, reducedtotal lung capacity, normal forced expiratoryvolume in 1 second/forced vital capacity[FVC] ratio) with reduced diffusing capacityof the lung for carbon monoxide (DLCO);however, the spirometry can be normal inmild disease or mixed obstructive-restrictive disorders (eg, coexisting emphy-sema).11 It is also important to rememberthat DLCO can be reduced by both

Mayo Clin Proc. n February 201

nloaded for Anonymous User (n/a) at Sint Antonius Hospital from CliFor personal use only. No other uses without permission. Copyright ©

pulmonary hypertension (PH) and emphy-sema. For serial monitoring, the FVC andDLCO are most commonly used, alongwith oximetry, which is used to monitorfor hypoxemia requiring oxygen supplemen-tation and as a potential indicator for lungtransplant evaluation.9,11

High-resolution computed tomography(HRCT) is essential in the initial evaluationof any suspected ILD. There is a good corre-lation between the extent of ILD assessed byHRCT and the degree of pulmonary impair-ment measured by FVC and DLCO.12,13 Inaddition to the pattern of ILD, HRCTprovides information on the airways,pulmonary artery, pleura, coexistingemphysema or cancer, and extrapulmonarystructures that may be relevant in the man-agement of the patient. The HRCT can bediagnostic of usual interstitial pneumonia(UIP), the histologic pattern seen in pa-tients with IPF. However, UIP can be seenwith CTD-ILD (particularly RA), as well asothers (eg, chronic hypersensitivity pneu-monitis).14-16 Thus, the clinical contextand correlation remain essential.

In established CTD, the role of a surgicallung biopsy remains uncertain. It may pro-vide prognostic information,17 but whetherit would alter management remains unclear.However, when there is uncertainty about anunderlying CTD, a lung biopsy may beimportant to distinguish from other intersti-tial pneumonias, particularly IPF. Surgicallung biopsy has the highest yield, but bron-choscopic cryobiopsy, which provides largerbiopsy specimens compared with traditionalforceps biopsy, may find an increasing rolein this regard.18 Bronchoalveolar lavage isneither diagnostic nor specific but may beused to rule out other processes, such asinfection or hemorrhage. DistinguishingIPF-UIP from a CTD-ILD whenever possiblehas significant therapeutic implications.Antifibrotic agents such as pirfenidone andnintedanib have been shown in clinical trialsto slow the loss of lung function in IPF; butin contrast, immunomodulators (eg, azathio-prine and prednisone) that are typically usedfor CTD-ILD may potentially be more harm-ful in IPF.19

9;94(2):309-325 n https://doi.org/10.1016/j.mayocp.2018.09.002www.mayoclinicproceedings.org

nicalKey.com by Elsevier on May 14, 2019.2019. Elsevier Inc. All rights reserved.



FIGURE 1. Histopathologic features suggestive of connective tissue diseaseerelated interstitial lung disease. A, Heavy lymphoplasmacytic infiltrates inthe alveolar interstitial septa, diagnostic for lymphocytic interstitial pneu-monia (hematoxylin-eosin, original magnification �200). B, Lymphoid fol-licle with prominent germinal center is seen in a background of interstitialfibrosis in a patient with rheumatoid arthritis (hematoxylin-eosin, originalmagnification �100).

ILD AND OTHER PULMONARY MANIFESTATIONS IN CTD

PATHOLOGY OF CTD-ILDAs alreadynoted, lung biopsymay be obtainedfor evaluation of ILD in some patients withouta clear diagnosis of CTD or atypical featureson clinical or radiologic presentation. Insuch patients, pathologic diagnosis of CTD-ILD can be challenging. Connective tissuediseaseerelated ILDs may show all majorpatterns seen in IIPs, including nonspecificinterstitial pneumonia (NSIP), UIP, lymphoidinterstitial pneumonia (LIP), organizingpneumonia (OP), acute interstitial pneu-monia/diffuse alveolar damage (DAD), and,in rare cases, desquamative interstitial pneu-monia.20,21 Of note, NSIP is more commonlyseen than is UIP in the setting of CTD-ILD(except in RA), whereas UIP is the most com-mon pattern in patients with IIPs.22 Thedistribution of histopathologic patterns variesdepending on the type of CTD, but there is nospecific association between any ILD patternand a particular CTD.

The histologic differences between CTD-UIP and IPF-UIP have not been clearlydefined. Cipriani et al23 proposed histologiccriteria to differentiate CTD-UIP from IPF-UIP by a quantitative pathologic study usingfibroblastic foci, lymphoid aggregates, andpresence of an NSIP pattern as the parame-ters (Figure 1). They concluded thatCTD-UIP had fewer and smaller fibroblastfoci than did IPF-UIP. Of patients withCTD-UIP, those with RA-UIP had moreand larger lymphoid aggregates than did pa-tients with IPF-UIP. Their study also showedthat the coexistence of UIP and NSIP pat-terns was one of the most salient featuresin distinguishing CTD-UIP from IPF-UIP.23

The histologic variability in different lobeshas also been demonstrated in patientswith IIPs.24 Surgical lung biopsies frommultiple lobes of 109 patients with IIPwere reviewed by 3 expert pulmonary pa-thologists, who assigned a diagnosis of UIPvs NSIP in each lobe. In 26% of 109 patientswith IIP, there was interlobar histologic vari-ability (ie, a UIP pattern in �1 lobe and anNSIP pattern in �1 lobe).

It has been recognized that many pa-tients thought to have IIP after lung biopsy

Mayo Clin Proc. n February 2019;94(2):309-325 n https://doi.org/1www.mayoclinicproceedings.org


manifest clinical or serologic features sug-gestive of an underlying autoimmune pro-cess without meeting the establishedcriteria for a CTD.3,4 The European Respira-tory Society and the American Thoracic Soci-ety (ATS) Task Force proposed the terminterstitial pneumonia with autoimmunefeatures (IPAF), which is elaborated on inmore detail later herein.4

IMAGING ASPECTS OF CTD-ILDVarious thoracic imaging abnormalities maybe encountered in patients with CTDs(Table 1),25,26 but the pattern associatedwith the greatest morbidity and mortality isILD. Therefore, when HRCT is performedfor patients with CTDs, assessment of thepresence and pattern of ILD is importantand is typically approached using the ATSconsensus criteria used for IIPs.26,27 Theseimaging patterns for ILD correlate with thosedescribed for histopathologic patterns.26

The UIP pattern on HRCT is character-ized by reticulation associated with fibroticfeatures, including architectural distortion,traction bronchiectasis, and possibly honey-combing.21,27 These findings are peripheraland basal predominant, although someupper lobe abnormality is typically present.Findings considered inconsistent with theUIP pattern include an upper or middlelung or peribronchovascular predominance,

0.1016/j.mayocp.2018.09.002

ntonius Hospital from ClinicalKey.com by Elsevier on May 14, t permission. Copyright ©2019. Elsevier Inc. All rights reserved

311

2019..



TABLE 1. Relative Frequencies of Computed Tomography Imaging Patterns Among CTDsa

CTD UIP NSIP OP LIP DAD Hemorrhage Airwayb Nodulesc Serositisd

RA þþþ þþ þþ þ þ � þþþ þþþ þþþSSc þ þþþ þ � þ � � � �PM/DM þ þþþ þþþ � þþ � � � �SjS þ þþ � þþ þ � þ þ �SLE þ þþ þ þþ þþ þþþ � � þþþMCTD þ þþ þ � � � � � þa� ¼ absence of finding; þ ¼ lowest and þþþ ¼ highest; CTD ¼ connective tissue disease; DAD ¼ diffuse alveolar damage pattern;LIP ¼ lymphocytic interstitial pneumonia pattern; MCTD ¼ mixed connective tissue disease; NSIP ¼ nonspecific interstitial pneumoniapattern; OP ¼ organizing pneumonia pattern; PM/DM ¼ polymyositis/dermatomyositis; RA ¼ rheumatoid arthritis; SjS ¼ Sjögrensyndrome; SLE ¼ systemic lupus erythematosus; SSc ¼ systemic sclerosis; UIP ¼ usual interstitial pneumonia pattern.bBronchiectasis, bronchial wall thickening, small centrilobular nodules (that may reflect follicular bronchiolitis), and constrictivebronchiolitis.cTypically �1 cm (not centrilobular).dPleural or pericardial fluid or thickening.


312

Dow

extensive ground-glass opacity, micronod-ules, discrete cysts, significant mosaic perfu-sion and air trapping, and consolidation.27

The NSIP pattern consists of bilateral,basal-predominant ground-glass opacityand reticulation associated with tractionbronchiectasis. The presence of fibrotic ab-normalities varies from minimal, in patientswith cellular NSIP, to pronounced, possiblywith honeycombing resembling UIP, in pa-tients with fibrotic NSIP. The pattern oflesser lung involvement adjacent to thepleura (subpleural sparing) suggests NSIP.28

The OP pattern consists of patchy,peripheral, often frankly subpleural, andperibronchiolar consolidation that maymigrate. Perilobular opacities and thereversed ground-glass halo sign may occur.The LIP pattern is often nonspecific atHRCT, but one manifestationdmultiple,thin-walled cystsdmay be recognized.29

The imaging appearances of the variousIIP patterns are generally indistinguishablefrom their CTD-associated counterparts,25

but several clues to a CTD-associated etiol-ogy may be recognized:

d Combined NSIP-OP pattern. When abasal-predominant fibrotic abnormalityshows a superimposed OP pattern(Figure 2), CTD, especially idiopathic in-flammatory myopathies (IIMs) or antisyn-thetase syndrome (AS), should be



suspected.21,30 Occasionally, AS presentswith acute respiratory failure and DADsuperimposed on a basal-predominant IIPpattern.25,31

d Unclassifiable interstitial pneumonia mayresult from atypical or mixed imagingfindings,27 including a peribronchovascu-lar distribution, or when DAD is superim-posed on another IIP pattern, potentiallyindicating the presence of CTD.25

d Clues favoring CTD-UIP over IPF-UIPinclude straight-edge sign (fairly straightand abrupt interface between fibrotic andnormal lung), exuberant honeycombingsign (extensive honeycomb cyst formationconstituting >70% of fibrotic-appearinglung), and anterior upper lobe sign (retic-ulation and honeycombing concentratedin the anterior upper lobes) (Figure 3).32

d Other thoracic imaging findings suggest-ing CTD.25 Other clues to the presenceof CTD and their relative prevalence,most commonly affecting the thorax, aredetailed in Table 1.

Radiology Report in CTDs: EssentialElementsSeveral elements should be included whenreporting HRCT results in patients withCTD:

d Presence of pulmonary parenchymal ab-normalities and the pattern of any





FIGURE 2. A mixed nonspecific interstitialpneumonia (NSIP) and organizing pneumonia(OP) pattern suggesting a connective tissuedisorder. Axial image through the upper (A)and middle (B) lungs shows patchy areas ofground-glass opacity with a peribronchiolardistribution (arrows), suggesting the presence ofOP. C, The lower lobes show peripheralground-glass opacity and reticulation, with sub-pleural sparing (arrows), more suggestive ofNSIP. Histopathologic sampling at multiplelevels showed the presence of both NSIP andOP. The patient was subsequently diagnosed ashaving polymyositis/dermatomyositis.


interstitial pneumonia using the ATSreporting scheme27

d Large main pulmonary artery size (>2.9mm or the main pulmonary artery largerthan the ascending aorta consideredabnormal), which may indicate the pres-ence of PH



d Findings that may indicate the etiology ofthe CTD (Table 1), such as serositis,airway disease, cysts, etc

d Findings that may indicate a complication,such as pneumonia or nodules measuring1 cm or larger, which can herald the devel-opment of lymphoma, particularly in thesetting of Sjögren syndrome (SjS)

For patients with systemic sclerosis(SSc), semiquantitative HRCT assessmentof pulmonary disease severity as limited orextensive combined with FVC assessmentmay segregate patients into low- and high-risk categories, potentially identifying pa-tients requiring treatment.33 The optimalHRCT threshold varies among studies evalu-ating this approach but clusters around 20%of total lung volume.33,34

SCLERODERMAScleroderma is a chronic autoimmune rheu-matic disease characterized by small-vesselvasculopathy and fibrosis of the skin andinternal organs. Immune-mediated mecha-nisms seem to be central to endothelial cellinjury accompanied by fibroblast recruit-ment and activation, which result in accu-mulation of extracellular matrix andfibrosis.35

Among the CTDs, scleroderma carriesthe highest case-based mortality, with me-dian survival after diagnosis estimated to be11 years.36 Approximately 50% to 55% ofdeaths are due to scleroderma itself.37,38

Systemic sclerosis is diagnosed when thecharacteristic skin abnormality is associatedwith internal organ involvement.

Pulmonary involvement occurs in morethan 80% of patients with scleroderma andincludes ILD (most common), pulmonaryarterial hypertension (PAH), pleural effu-sion, constrictive bronchiolitis, respiratorymuscle weakness, and aspiration pneumonia(related to esophageal dysfunction).37,39 Inrecent years, ILD and PAH have becomethe main causes of scleroderma-relateddeaths, surpassing renal crisis.37,38,40

Patients with SSc-ILD typically presentwith exertional dyspnea or cough but maysometimes be asymptomatic.41-43 Inspiratory

0.1016/j.mayocp.2018.09.002 313




FIGURE 3. High-resolution computed tomographic findings suggesting usual interstitial pneumonia in thecontext of rheumatoid arthritis over usual interstitial pneumonia and idiopathic pulmonary fibrosis. A,Prone image shows extensive basal fibrosis characterized by extensive honeycombing, consistent with theexuberant honeycombing sign. Axial imaging through the upper (B) and lower (C) lobes shows substantialupper lobe subpleural reticulation and honeycombing, concentrated anteriorly, as pronounced as the basalfibrotic findings, consistent with the anterior upper lobe sign. D, Coronal image of the left lung showsbasal-predominant honeycomb lung and fibrotic changes with an abrupt transition from the extensivelyinvolved basal lung, forming a fairly straight interface between the region of extensive fibrosis inferiorly andthe less involved lung superiorly (arrowheads), consistent with the straight-edge sign.


314

Dow

crackles are usually present, but digital club-bing is rare. Occasionally, a restrictivepattern on pulmonary function results mayrelate to diffuse thoracic cutaneous sclerosisor respiratory muscle weakness41-43; DLCOthat is reduced out of proportion to theFVC in the absence of coexisting emphy-sema should raise suspicion for the presenceof PH.44 Parenchymal abnormalities seen onHRCT most commonly reflect an NSIPpattern14; less commonly, a UIP pattern isseen. Other HRCT findings may include pul-monary artery enlargement suggestive of PHand esophageal dilatation.

Diagnosis of SSc-ILD is generallyachieved in the presence of an NSIP orUIP pattern on HRCT of the chest anddoes not require histopathologic confirma-tion. Unexpected findings on imaging oratypical clinical features suggestive of otherprocesses, including drug toxicity andinfection, may necessitate further diagnosticevaluation, such as bronchoscopy and lungbiopsy.



Most patients with SSc-ILD experiencegradual progression reflected in increasingfibrotic changes on imaging and decline inpulmonary function.34 Acute exacerbationof ILD may occur, as seen in other chronicfibrotic ILDs, and likely shortens survival.Predictors of mortality in patients with SSc-ILD include age, FVC, DLCO, HRCT fibrosisseverity, bronchoalveolar lavage fluid neu-trophilia, and presence of PH.45 Mortalityrisk prediction models that may assist inprognostication for individual patients areavailable.34,46,47

Pharmacologic therapy with mycopheno-late mofetil or cyclophosphamide providesmodest benefit for patients with SSc-ILD.A 12-month clinical trial comparing oralcyclophosphamide with placebo showed aslightly reduced rate of decline in FVC(expressed as percentage of predicted) favor-ing cyclophosphamide therapy (mean �SD, �1.0�0.92 vs �2.6�0.9, respectively;P<.03).48 There were also slight differencesin physiologic and symptom outcomes






favoring the cyclophosphamide group. In asubsequent clinical trial, mycophenolatemofetil therapy was shown to providesimilar benefits compared with oral cyclo-phosphamide but with less drug-relatedtoxicity.49 Based on these results, otherstudies of an observational nature, and clin-ical experience, mycophenolate mofetil ther-apy is currently favored in the treatment ofpatients with SSc-ILD.50 However, the deci-sions regarding who to treat and when toinitiate therapy remain difficult because thebenefits of pharmacologic therapy aremodest and the downsides, including drug-related toxicities, are significant. Althoughlow-dose prednisone has been used, therole of corticosteroids is limited in patientswith SSc-ILD because the risk of renal crisisis associated with prednisone dose greaterthan 15 mg/d.51 The potential therapeuticroles of antifibrotic agents (ie, pirfenidoneand nintedanib), biologic targeted therapies(eg, rituximab, tocilizumab, and fresolimu-mab), and autologous stem cell transplantremain to be clarified and continue to beinvestigated.

RHEUMATOID ARTHRITISThe most common lung manifestation of RAis ILD, coming to clinical attention inapproximately 10% of the RA population.52

An additional 30% of patients with RAhave subclinical lung disease. Although theincidence of some extra-articular diseaseinvolvement, such as vasculitis, has beendiminishing in recent years with the adventof more effective therapies for RA, there isno evidence that the prevalence of RA-ILDhas decreased.53 Lung disease may precedethe development of joint disease in up to20% of patients who have RA-ILD.

Middle-aged men; those with a smokinghistory of greater than 25 pack-years, whoare positive for rheumatoid factor or antici-trullinated peptide antibodies; those withother extra-articular disease manifestations;and those with the human leukocyteantigeneantigen Derelated double-sharedepitope are at particular risk for the develop-ment of RA-ILD.52,54



The most common pattern of RA-ILD isUIP in most series of patients in Westerncountries. However, a study from Chinareported that 58% of 237 patients with RA-ILD had an NSIP pattern on HRCT.54

Histopathologic evaluation of RA-ILDhas revealed an increased presence of citrul-linated proteins compared with patients withILD without RA.55 An increase in CD20- andCD168-positive lymphocytes has beenreported in patients with RA-NSIP and RA-UIP compared with patients with idiopathicNSIP or UIP. These and other findingshave led to consideration of the lung asbeing ground zero for the generation of auto-immunity in RA, with aberrant antigenpresentation in the lung, particularly in pa-tients who are smokers.56

Rheumatoid arthritis ILD progresses at avariable rate. Five years after ILD diagnosis,20% of patients will progress to an FVC ofless than 50%, and 40% will progress to aDLCO of less than 40%.16 The 1-year mortal-ity is reported to be 14% in patients withRA-ILD compared with 4% in patients withnon-ILD RA, and 10-year mortality was60% and 35%, respectively.57 The risk ofdeath for individuals with RA-ILD is approx-imately 3-fold higher than that for patientswith RA without ILD. Median survival afterthe diagnosis of RA-ILD is approximately2.6 years, and it is responsible for 10% to20% of all RA-related mortality.52,53,58

To date, no immunosuppressive orimmunomodulatory therapies have beenconsistently shown to stabilize or improveRA-ILD. Indeed, especially elderly patientswith RA given high doses of glucocorticoste-roids and chemotherapy are at high infectionrisk, and, in general, the evidence for efficacyof this therapy for RA-ILD is very limited.59

Of the biologicals having potential utility forthe treatment of RA and other CTD-ILD,rituximab has had the most interest, butwith mixed results. Note that virtually allnonbiological and biological disease-modifying antirheumatic drugs have beenassociated with pulmonary toxicity,although, in general, this risk is low.59 Anti-fibrotic therapy may also be a promisingapproach to the management of RA-ILD.

0.1016/j.mayocp.2018.09.002 315





316

Dow

Currently, a randomized clinical trial is un-derway examining pirfenidone.60

SYSTEMIC LUPUS ERYTHEMATOSUSLung involvement in systemic lupus erythe-matosus (SLE) is common and can affect anycompartment, with pleurisy being mostcommon, although more severe diseasemanifestations can rarely occur. Lupuspneumonitis is a feared complication ofSLE, characterized on histology by acutelung injury. It can present with rapidly pro-gressive dyspnea, fever, unilateral or bilateralinfiltrates, and, occasionally, hemoptysis,and may be seen as part of the presentingfeatures of SLE. Pathology may showdeposits of immune complexes composedof DNA, anti-DNA antibody, and comple-ment and deposits of DNAeanti-DNAimmune complexes.61 Progression to respi-ratory failure is common and results inhigh mortality. Diffuse alveolar hemorrhage(DAH) can occur in this syndrome, althoughDAH may occur for other reasons related toSLE, including antiphospholipid syndrome,and distinguishing these entities can bechallenging.62

Patterns of ILD such as UIP, NSIP, andLIP have been described in SLE63 but areless common than in scleroderma, IIM, orRA.

Shrinking lung syndrome is rarely seenin SLE, is characterized by dyspnea, and isoften accompanied by pleurisy (>60%).Typically, FVC and DLCO are reduced,although DLCO corrected for alveolarvolume is usually normal. Shrinking lungsyndrome is suspected in patients with SLEwho have dyspnea with normal lung paren-chyma on HRCT (ie, no evidence of ILD)and no evidence of PH but abnormal pulmo-nary function test results. The etiology maybe related to pleural changes, pain, and sub-tle changes in lung density that affectcompliance, and, thus, limit normal inspira-tion. Esophageal balloon manometry may behelpful to assess lung compliance and chestwall and pleural dynamics.64 If inflammationaround the lung is suspected, it should betreated; if pain is the predominant feature,then treatment of the pain may be helpful



to limit compliance changes and preservefunctional capacity.

In SLE with antiphospholipid syndrome,thromboembolic disease leading to PH,capillaritis with or without overt hemopty-sis, or DAH and acute respiratory distresssyndrome can develop.65 In those cases,high-dose glucocorticoids combined withcytotoxic therapy, B-celledeleting therapy,and plasmapheresis may be necessary.66

SJÖGREN SYNDROMESjögren syndrome is characterized by CD4T-cell infiltration of lacrimal and salivaryglands, increased interferon-g andinterleukin-2 production, and abnormalB-cell activation, resulting in autoantibodyproduction, hypergammaglobulinemia, andincreased risk of lymphoma. Xerotrachea,pleuritis, and airway and parenchymal lungdisease have all been described in patientswith SjS.

All forms of ILD, including NSIP, UIP,and LIP, have been described in SjS, andthey can be progressive.63 Clinical presenta-tions of ILD may be obscured due to thepresence of cough in patients with SjS,related to xerotrachea or small airwaysdisease such as constrictive or follicularbronchiolitis as a manifestation of LIP,where lymphoplasmacytic infiltrates caninvolve airways and result in obstruction.67

Male smokers are at the highest risk forILD.63

In cases in which new nodules are noted,the possible development of lymphoma andamyloidosis must be considered.68,69 Therisk of lymphoma in SjS is 3% to 5% greaterthan that in the general population and caninclude mucosa-associated lymphoid tissue,diffuse B-cell, and follicular lymphomas.Risk factors for the development of lym-phoma include extraglandular features,such as cutaneous vasculitis, neuropathy,rheumatoid factor positivity, and the pres-ence of cryoglobulins.70

IIMS AND ASThe IIMs include a group of disorders char-acterized by muscle inflammation from anautoimmune attack, leading to muscle






weakness. Although the main manifestationis myositis, as the name implies, extramus-cular involvement is common and can bemore clinically significant than myositisitself. For example, swallowing abnormal-ities, cardiac involvement, and pulmonarydisease are all frequently found. Amongthese manifestations, ILD has a prevalenceof 30% to 40% and is associated with an esti-mated mortality of 40%.71 Recognition ofautoantibodies has led to consideration ofhumoral immune etiology as an explanationfor all manifestations, but particularly inILD, because more than 75% of patientswho are serologically positive (eg, antisyn-thetase antibodies) develop ILD.72-75

Antibodies against melanomadifferentiationeassociated gene 5 are associ-ated with amyopathic dermatomyositis andthe development of acute and rapidly pro-gressive ILD.75 Myositis-associated andmyositis-specific antibodies are detectablein the sera of 50% of patients with polymyo-sitis/dermatomyositis. Myositis-associatedantibodies are not specific to polymyositis/dermatomyositis and are found in a varietyof autoimmune diseases. In contrast,myositis-specific antibodies seem to definespecific clinical phenotypes. Myositis-associated antibodies are classified by theirtarget into 4 groups; the most relevant arethose targeted against ribonucleoproteinsinvolved in protein synthesis (antieaminoacyl-tRNA synthetase [ARS] anti-bodies, also known as antisynthetase anti-bodies).76 Jo1 is the most common ARSantibody, but 7 more have been discoveredto date (PL7, PL12, OJ, EJ, KS, Zo, and Ha).

Antisynthetase syndrome corresponds tothe combination of an inflammatory myop-athy and the presence of antisynthetase anti-body. It is characterized by the associationwith other features, such as mechanic’shands, Raynaud phenomenon, fever, and,more importantly, ILD.77-80 Different pheno-types of AS have been recognized based onit, with more muscle involvement seen inanti-Jo1, anti-EJ, and anti-PL7.79,80

The prevailing pathologic patterns areOP, UIP, NSIP, and DAD, which coincidewith the described HRCT findings.80-82



Interestingly, HRCT features of NSIP patterncombined with subpleural and peribroncho-vascular areas of consolidation, resemblingOP, seem to be relatively common in AS.83

Because AS was first identified in patientcohorts with IIM (ie, dermatomyositis orpolymyositis), it has usually been treatedby protocols primarily designed for myositis,most often with high-dose corticosteroids asthe mainstay drug; however, the availabledata so far indicate that the major determi-nant of morbidity and mortality in this entityis the presence of ILD, and in many cases,there is corticosteroid resistance that neces-sitates the use of other immunosuppressivemedications, such as mycophenolate, whichis supported by only retrospective data.50

Other options, such as calcineurin inhib-itors (tacrolimus or cyclosporine), have beenevaluated in the refractory form of thedisease.84,85 There has been growing enthu-siasm for the use of rituximab, a monoclonalantibody against the CD20 B-cell surfacemarker, in the treatment of this entity.86

VASCULITISSystemic vasculitis typically has been associ-ated with non-ILD pulmonary manifesta-tions, such as lung nodules or DAH.87

Recently, however, ILD has been recognizedin patients with antineutrophil cytoplasmicantibody (ANCA)eassociated vasculitis,particularly if they are positive for antimye-loperoxidase antibodies.88,89

A few small series, mostly retrospective,have identified specific features of patientswith positive antimyeloperoxidase anti-bodies and pulmonary fibrosis. The mostcommon radiographic and pathologicpattern is UIP, and less commonly NSIP90;it seen more often in men and at an olderage compared with other CTDs, with amean age at onset typically in the late60s.89,91,92 Interstitial lung disease eitherprecedes or occurs concomitantly with theonset of vasculitic features.88-92 Asmentioned previously herein, the clinicalpicture and demographic characteristicscould be very similar to those of patientswith IPF; however, increased attenuationaround areas of honeycombing and cystic

0.1016/j.mayocp.2018.09.002 317





318

Dow

lesions are seen more often. On histology,patients with ANCA-ILD had more promi-nent inflammatory cell infiltration, germinalcenters, lymphoid follicles, and cellularbronchiolitis compared with patients withIPF.93

Most patients with ANCA-ILD reportedin the literature have been positive for p-ANCA and antimyeloperoxidase antibody88-93;however, data from our group found thatapproximately one-third of the patientswith ANCA-associated vasculitis and ILDwere c-ANCA/proteinase-3 positive, a higherpercentage than previously reported.94

The mortality rate of patients withANCA-ILD seems to be higher comparedwith that of patients with CTD-ILDs, andmore similar to patients with IPF89,91,95;however, a small study reported that immu-nosuppressive treatment tended to be moreeffective in patients with ANCA-UIPcompared with patients with IPF.93

INTERSTITIAL PNEUMONIA WITH AUTOIM-MUNE FEATURESAs previously mentioned, many patientswith IIP have subtle features suggestive ofan autoimmune etiology, and these individ-uals quite often do not meet the classifica-tion criteria for a specific CTD.1,96 It haseven been suggested that idiopathic NSIP isan autoimmune disease or the lung manifes-tation of undifferentiated CTD.97,98 Withgenerally improved outcomes associatedwith CTD-ILD,9 and because different treat-ment approaches are often implemented inthese patients,99 determining whether sug-gestive forms of autoimmune ILD representa spectrum of CTD-ILD, rather than IIP, isimportant.

The terms undifferentiated CTD,98,100

lung-dominant CTD,2 and autoimmune-featured ILD101 have all been used todescribe patients with suggestive forms ofCTD-ILD. Each of these categories has aunique set of proposed criteria and repre-sents the ideas of investigative teams fromdistinct ILD referral centers. These sets ofcriteria are different enough that researchstudies being implemented in various cen-ters using one set of criteria may not be



applicable to cohorts from centers usingother sets of criteria. In an effort to buildconsensus, a European Respiratory Societyand ATS Task Force, “An InternationalWorking Group on Undifferentiated Formsof CTD-ILD,” was formed to developconsensus regarding nomenclature andcriteria for classification of suggestive formsof autoimmune ILD.4 The term interstitialpneumonia with autoimmune features wasproposed by this Task Force.4 The term con-nective tissue disease was specifically avoideddue to concerns that such labeling gives afalse impression that these individuals havea defined CTD.

Classification Criteria for IPAFThere are several a priori requirements forthe classification of IPAF. Individuals musthave evidence of interstitial pneumonia byHRCT or surgical lung biopsy and a thor-ough clinical evaluation during whichknown causes for interstitial pneumoniahave been excluded, and they must notmeet the criteria for a defined CTD. The clas-sification criteria are then organized around3 central domains: a clinical domain consist-ing of specific extrathoracic features; a sero-logic domain consisting of specificcirculating autoantibodies; and a morpho-logic domain consisting of specific chest im-aging and histopathologic or pulmonaryphysiologic features. To be classified as hav-ing IPAF, the individual must meet all of thea priori requirements and have at least 1feature from at least 2 of the domains(Table 2).4

Historically, the lack of consensus oncriteria limited the ability to draw firm con-clusions about this group of patients.102

With IPAF, uniform terminology and classi-fication criteria for related but potentiallydistinct entities (undifferentiated CTD-ILD,lung-dominant CTD, and autoimmune-featured ILD) has been systematically devel-oped and ratified. A strength of the IPAFnomenclature and definition is that its classi-fication criteria were derived based on inter-national and multidisciplinary consensus,although a variety of important limitationswere acknowledged.4





TABLE 2. Classification Criteria for Interstitial Pneumonia With Autoimmune Featuresa

1. Presence of an interstitial pneumonia (by HRCT or surgical lung biopsy)

2. Exclusion of alternative etiologies

3. Does not meet the criteria of a defined CTD

4. At least 1 feature from �2 of these domains:A. Clinical domainB. Serologic domainC. Morphologic domain

A. Clinical domain1. Distal digital fissuring (ie, “mechanic hands”)2. Distal digital tip ulceration3. Inflammatory arthritis or polyarticular morning joint stiffness �60 min4. Palmar telangiectasia5. Raynaud phenomenon6. Unexplained digital edema7. Unexplained fixed rash on the digital extensor surfaces (Gottron sign)

B. Serologic domain1. ANA �1:320 titer, diffuse, speckled, homogeneous patterns ora. ANA nucleolar pattern (any titer) orb. ANA centromere pattern (any titer)

2. RF �2 � ULN3. Anti-CCP4. Anti-dsDNA5. Anti-Ro (SS-A)6. Anti-La (SS-B)7. Antiribonucleoprotein8. Anti-Smith9. Antitopoisomerase (Scl-70)10. Anti-tRNA synthetase (eg, Jo-1, PL-7, PL-12, (others are: EJ, OJ, KS, Zo, tRS)11. Anti-PM-Scl12. Anti-MDA-5

C. Morphologic domain1. Suggestive radiology patterns by HRCT (see text for descriptions):a. NSIPb. OPc. NSIP with OP overlapd. LIP

2. Histopathology patterns or features by surgical lung biopsy:a. NSIPb. OPc. NSIP with OP overlapd. LIPe. Interstitial lymphoid aggregates with germinal centersf. Diffuse lymphoplasmacytic infiltration (with or without lymphoid follicles)

3. Multicompartment involvement (in addition to IP):a. Unexplained pleural effusion or thickeningb. Unexplained pericardial effusion or thickeningc. Unexplained intrinsic airways diseaseb (by pulmonary function tests, imaging, or pathology)d. Unexplained pulmonary vasculopathy

aANA ¼ antinuclear antibody; CTD ¼ connective tissue disease; HRCT ¼ high-resolution computed tomography; IP ¼ interstitialpneumonia; LIP ¼ lymphoid interstitial pneumonia; NSIP ¼ nonspecific interstitial pneumonia; OP ¼ organizing pneumonia;RF ¼ rheumatoid factor; SS-A ¼ Sjögren syndromeerelated antigen A; SS-B, Sjögren syndromeerelated antigen B; ULN ¼ upper limitof normal.bIncludes airflow obstruction, bronchiolitis, or bronchiectasis.


Mayo Clin Proc. n February 2019;94(2):309-325 n https://doi.org/10.1016/j.mayocp.2018.09.002www.mayoclinicproceedings.org

319

Downloaded for Anonymous User (n/a) at Sint Antonius Hospital from ClinicalKey.com by Elsevier on May 14, 2019.For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.




320

Dow

Since the initial publication of IPAF,several publications from diverse ILD pro-grams describe characteristics and the natu-ral history of IPAF from their respectivecenters around the world.103-107 Each ofthe cohorts was retrospectively formed andaffected by referral bias and/or how IPAFcriteria were applied. It has become clearthat as devised, the current definition ofIPAF has been noted to allow for significantheterogeneity. For example, the Chicagocohort107 had a UIP pattern-predominantcohort and looked a lot like IPF, and theDenver cohort106 was NSIP predominant,with a large number of patients with specificautoimmune serologic positivity (eg, anti-ARS antibodies). Within the current frame-work, some ambiguity in the definition ofIPAF may allow a subset of patients with aUIP pattern of disease (who may have IPF)to fulfill the criteria for IPAF. Another areaof concern relates to discrepancies amongcenters and experts around those with a pos-itive anti-ARS antibody and ILD. In theabsence of cutaneous features of dermatomy-ositis or evidence of myositis there can bedisagreement regarding what one considersto be incomplete forms of the AS vsIPAF.108,109 As the heterogeneity is acknowl-edged, one advantage of IPAF is that uni-form nomenclature has been adopted,prospective research studies from diverseprograms are using similar classificationcriteria, and data are being gathered to allowfor refinement of the criteria. Furthermore,there is now more interdisciplinary involve-ment in this arena.

It is recognized that the IPAF criteriamust be tested and validated in future pro-spective studies, and modifications high-lighting the importance of longitudinalsurveillance of affected patients will beneeded.4,110 Adopting IPAF means leavingbehind the previous terminologies andallows for future study of a more uniformcohort. Prospective studies are urgentlyneeded to refine the first draft of the pro-posed classification criteria and to determinethe natural history and clinical implicationsof a classification of IPAF.



PH IN CTDConnective tissue disease, particularlyscleroderma, is associated with all diagnosticgroups of PH. For example, the pulmonaryartery vasculature can narrow as a conse-quence of CTD, producing increasingpulmonary vascular resistance and group 1PAH. Indeed, CTD is the second most com-mon cause of group 1 PAH.111 Conversely,group 1 PAH develops in approximately10% of patients with scleroderma.112 Inaddition, left heart disease, such as heart fail-ure with preserved ejection fraction, is notuncommon due to systemic hypertension,resulting in group 2 pulmonary venoushypertension. Last, associated ILD and hyp-oxemia can produce group 3 PH in connec-tion with lung disease.

It is important to maintain a high indexof suspicion for PH as a potential cause inpatients with CTD with new-onset dyspnea.Indeed, approximately 25% of group 1 PAHis due to CTD. Screening with echocardiog-raphy can be helpful, particularly in patientswith scleroderma and risk factors for PAH,such as positive anticentromere antibodyand telangiectasias. Multiple screening stra-tegies have proved successful in increasingdiagnostic yield (sensitivity of 96%-100%).113 Conversely, use of antinuclearantibody testing to screen for CTD inpatients with PAH is recommended.114

Confirmation of diagnosis requires rightheart catheterization and subspecialty evalu-ation, preferably in an accredited pulmonaryvascular center.115

Unfortunately, treatment tailored to con-trolling the underlying CTD does not seemto have much effect on the associated PAH.Exceptions may include SLE and active sys-temic vasculitis. In addition, there is littleto suggest that treatments targeting ILDhave any ameliorating effect on PAH.116

Nonetheless, there is clear evidence in sup-port of PAH-specific therapies to lessensymptom burden and reduce clinicallymeaningful events, such as hospitalization(risk reduction, 57%).117 Hospitalizationrepresents a major risk in patients withgroup 1 PAH,118 and combination






PAH-specific therapy reduced all-cause hos-pitalization from 15% to 5% compared withsingle-drug treatment regimens.117 Currenttreatment guidelines advocate oral PAH ther-apy with strong consideration for combina-tion treatment in New York HeartAssociation functional classes II and III,and infusion prostanoid therapy for func-tional class IV patients.119 Unfortunately,PAH-specific treatment may not be as effec-tive in CTD-PAH based on a review of 11randomized controlled trials comparing 827patients with CTD-PAH with 1935 patientswith idiopathic PAH, with less benefit in 6-minute walk distance and reduction in clin-ical worsening.120 Of note, randomized pro-spective trials of PAH-specific therapy ingroup 3 PH patients with ILD have univer-sally failed to prove benefit.121-123

Prognosis is generally worse for PAH-CTD compared with other group 1 sub-groups (83% vs 93% at 1-year survival;P<.001).124 It seems that patients withPAH-SLE may be the exception, with 5-year survival of 84%; anti-U1 ribonucleopro-tein antibody may be an indicator of betteroutcome.125 Conversely, patients withscleroderma-related PAH fare worse, particu-larly men older than 60 years with low sys-temic blood pressure (systolic <110 mmHg) or 6-minute walk distance (<165 m)and severely abnormal hemodynamics (eg,right atrial pressure of 20 mm Hg).126 Echo-cardiography may provide a simplifiedapproach to prognostication.127

CONCLUSIONThe presenting features of CTD-ILDcomprise a broad spectrum of clinical, imag-ing, and pathologic patterns. Diagnosis re-quires a comprehensive medical evaluationand multidisciplinary correlation of thesefeatures. In some patients, lung biopsy maybe needed to clarify the nature of the lungdisease. Distinguishing CTD-ILD from idio-pathic forms of ILD, such as IPF, has treat-ment and prognostic implications but maybe difficult in some patients as illustratedby the concept of IPAF. In general, immuno-suppressive agents are used in the treatment



of CTD-ILD, although the data supportingthese treatment strategies are relativelysparse. The role of antifibrotic agents inCTD-ILDs remains to be defined. Compli-cating factors, such as gastroesophagealreflux disease and PH, need to be identifiedand managed accordingly.

Abbreviations and Acronyms: ANA = antinuclear anti-body; ANCA = antineutrophil cytoplasmic antibody; ARS =aminoacyl-tRNA synthetase; AS = antisynthetase syndrome;ATS = American Thoracic Society; CTD = connective tissuedisease; CTD-ILD = connective tissue diseaseerelatedinterstitial lung disease; DAD = diffuse alveolar damage;DAH = diffuse alveolar hemorrhage; DLCO = diffusing ca-pacity of the lung for carbon monoxide; FVC = forced vitalcapacity; HRCT = high-resolution computed tomography;IIM = idiopathic inflammatory myopathy; IIP = idiopathicinterstitial pneumonia; ILD = interstitial lung disease; IP =interstitial pneumonia; IPAF = interstitial pneumonia withautoimmune features; IPF = idiopathic pulmonary fibrosis;LIP = lymphoid interstitial pneumonia; NSIP = nonspecificinterstitial pneumonia; OP = organizing pneumonia; PAH =pulmonary arterial hypertension; PH = pulmonary hyper-tension; PM/DM = polymyositis/dermatomyositis; RA =rheumatoid arthritis; RF = rheumatoid factor; SjS = Sjögrensyndrome; SLE = systemic lupus erythematosus; SS-A =Sjögren syndromeerelated antigen A; SS-B = Sjögrensyndromeerelated antigen B; SSc = systemic sclerosis; UIP= usual interstitial pneumonia; ULN = upper limit of normal

Potential Competing Interests: Dr Burger has received un-restricted research grants from Actelion Pharmaceuticals Incand United Therapeutics. Dr Dellaripa received payment forwriting or reviewing the manuscript from UpToDate, hasparticipated in research projects in conjunction with Genen-tech, and receives royalties from UpToDate and SpringerPublications. Dr Fischer has served as a consultant to Boeh-ringer Ingelheim and F Hoffman La Roche, and has receivedgrants from Boehringer Ingelheim and Corbus Pharmaceuti-cals. Dr Joyce S. Lee has received grants from the NationalInstitutes of Health and has been a 1-time advisory boardmember for Celgene, Genentech, and Boehringer Ingelheim.Dr Matteson has served as a board member for Janssen andas a consultant for Amgen; has received grants from Pfizer,GlaxoSmithKline, and Sun Pharmaceutical Industries Ltd; andreceives royalties from UpToDate. The rest of the authorsreport no competing interests.

Correspondence: Address to Isabel Mira-Avendano, MD,Division of Pulmonary, Allergy, and Sleep Medicine, MayoClinic, 4500 San Pablo Rd, Jacksonville, FL 32224 ([email protected]).

REFERENCES1. Fischer A, du Bois R. Interstitial lung disease in connective tis-

sue disorders. Lancet. 2012;380(9842):689-698.2. Fischer A, West SG, Swigris JJ, Brown KK, du Bois RM. Con-

nective tissue disease-associated interstitial lung disease: acall for clarification. Chest. 2010;138(2):251-256.

0.1016/j.mayocp.2018.09.002 321


mailto:[email protected]

mailto:[email protected]




322

Dow

3. Vij R, Strek ME. Diagnosis and treatment of connective tissuedisease-associated interstitial lung disease. Chest. 2013;143(3):814-824.

4. Fischer A, Antoniou KM, Brown KK, et al. An official EuropeanRespiratory Society/American Thoracic Society researchstatement: interstitial pneumonia with autoimmune features.Eur Respir J. 2015;46(4):976-987.

5. Fischer A, Swigris JJ, Groshong SD, et al. Clinically significantinterstitial lung disease in limited scleroderma: histopathology,clinical features, and survival. Chest. 2008;134(3):601-605.

6. Flaherty KR, Colby TV, Travis WD, et al. Fibroblastic foci inusual interstitial pneumonia: idiopathic versus collagen vasculardisease. Am J Respir Crit Care Med. 2003;167(10):1410-1415.

7. Marigliano B, Soriano A, Margiotta D, Vadacca M, Afeltra A.Lung involvement in connective tissue diseases: a comprehen-sive review and a focus on rheumatoid arthritis. AutoimmunRev. 2013;12(11):1076-1084.

8. Zamora-Legoff JA, Krause ML, Crowson CS, Ryu JH,Matteson EL. Risk of serious infection in patients with rheuma-toid arthritis-associated interstitial lung disease. Clin Rheumatol.2016;35(10):2585-2589.

9. Park JH, Kim DS, Park IN, et al. Prognosis of fibrotic interstitialpneumonia: idiopathic versus collagen vascular disease-relatedsubtypes. Am J Respir Crit Care Med. 2007;175(7):705-711.

10. Aparicio IJ, Lee JS. Connective tissue disease-associated inter-stitial lung diseases: unresolved issues. Semin Respir Crit CareMed. 2016;37(3):468-476.

11. Aduen JF, Zisman DA, Mobin SI, et al. Retrospective study ofpulmonary function tests in patients presenting with isolatedreduction in single-breath diffusion capacity: implications forthe diagnosis of combined obstructive and restrictive lung dis-ease. Mayo Clin Proc. 2007;82(1):48-54.

12. Marie I, Josse S, Decaux O, et al. Comparison of long-termoutcome between anti-Jo1- and anti-PL7/PL12 positive pa-tients with antisynthetase syndrome. Autoimmun Rev. 2012;11(10):739-745.

13. Andersson H, Aalokken TM, Gunther A, et al. Pulmonaryinvolvement in the antisynthetase syndrome: a comparativecross-sectional study. J Rheumatol. 2016;43(6):1107-1113.

14. Ohno Y, Koyama H, Yoshikawa T, Seki S. State-of-the-art im-aging of the lung for connective tissue disease (CTD). CurrRheumatol Rep. 2015;17(12):69.

15. Sverzellati N, Lynch DA, Hansell DM, Johkoh T, King TE Jr,Travis WD. American Thoracic Society-European RespiratorySociety Classification of the Idiopathic Interstitial Pneumonias:advances in knowledge since 2002. Radiographics. 2015;35(7):1849-1871.

16. Zamora-Legoff JA, Krause ML, Crowson CS, Ryu JH,Matteson EL. Progressive decline of lung function in rheuma-toid arthritis-associated interstitial lung disease. Arthritis Rheu-matol. 2017;69(3):542-549.

17. Moua T, Zamora Martinez AC, Baqir M, Vassallo R,Limper AH, Ryu JH. Predictors of diagnosis and survival inidiopathic pulmonary fibrosis and connective tissue disease-related usual interstitial pneumonia. Respir Res. 2014;15:154.

18. Lentz RJ, Taylor TM, Kropski JA, et al. Utility of flexible bron-choscopic cryobiopsy for diagnosis of diffuse parenchymallung diseases. J Bronchology Interv Pulmonol. 2018;25(2):88-96.

19. Raghu G, Anstrom KJ, King TE Jr, Lasky JA, Martinez FJ. Idio-pathic Pulmonary Fibrosis Clinical Research Network. Predni-sone, azathioprine, and N-acetylcysteine for pulmonaryfibrosis. N Engl J Med. 2012;366(21):1968-1977.

20. Doyle TJ, Dellaripa PF. Lung manifestations in the rheumaticdiseases. Chest. 2017;152(6):1283-1295.

21. Travis WD, Costabel U, Hansell DM, et al. An official Amer-ican Thoracic Society/European Respiratory Society state-ment: update of the international multidisciplinaryclassification of the idiopathic interstitial pneumonias. Am JRespir Crit Care Med. 2013;188(6):733-748.



22. Nagai S, Handa T, Tabuena R, Kitaichi M, Izumi T. Nonspecificinterstitial pneumonia: a real clinical entity? Clin Chest Med.2004;25(4):705-715, vi.

23. Cipriani NA, Strek M, Noth I, et al. Pathologic quantification ofconnective tissue disease-associated versus idiopathic usualinterstitial pneumonia. Arch Pathol Lab Med. 2012;136(10):1253-1258.

24. Flaherty KR, Travis WD, Colby TV, et al. Histopathologic vari-ability in usual and nonspecific interstitial pneumonias. Am JRespir Crit Care Med. 2001;164(9):1722-1727.

25. Henry TS, Little BP, Veeraraghavan S, Bhalla S, Elicker BM. Thespectrum of interstitial lung disease in connective tissue dis-ease. J Thorac Imaging. 2016;31(2):65-77.

26. Bryson T, Sundaram B, Khanna D, Kazerooni EA. Connectivetissue disease-associated interstitial pneumonia and idiopathicinterstitial pneumonia: similarity and difference. Semin Ultra-sound CT MR. 2014;35(1):29-38.

27. Raghu G, Rochwerg B, Zhang Y, et al. An official ATS/ERS/JRS/ALAT clinical practice guideline: treatment of idiopathic pul-monary fibrosis: an update of the 2011 clinical practice guide-line. Am J Respir Crit Care Med. 2015;192(2):e3-e19.

28. Capobianco J, Grimberg A, Thompson BM, Antunes VB,Jasinowodolinski D, Meirelles GS. Thoracic manifestations ofcollagen vascular diseases. Radiographics. 2012;32(1):33-50.

29. Egashira R, Kondo T, Hirai T, et al. CT findings of thoracicmanifestations of primary Sjogren syndrome: radiologic-pathologic correlation. Radiographics. 2013;33(7):1933-1949.

30. Debray MP, Borie R, Revel MP, et al. Interstitial lung disease inanti-synthetase syndrome: initial and follow-up CT findings.Eur J Radiol. 2015;84(3):516-523.

31. Tillie-Leblond I, Wislez M, Valeyre D, et al. Interstitial lung dis-ease and anti-Jo-1 antibodies: difference between acute andgradual onset. Thorax. 2008;63(1):53-59.

32. Chung JH, Cox CW, Montner SM, et al. CT features of theusual interstitial pneumonia pattern: differentiating connectivetissue disease-associated interstitial lung disease from idio-pathic pulmonary fibrosis. AJR Am J Roentgenol. 2018;210(2):307-313.

33. Wells AU, Margaritopoulos GA, Antoniou KM, Denton C.Interstitial lung disease in systemic sclerosis. Semin Respir CritCare Med. 2014;35(2):213-221.

34. Goh NS, Desai SR, Veeraraghavan S, et al. Interstitial lung dis-ease in systemic sclerosis: a simple staging system. Am J RespirCrit Care Med. 2008;177(11):1248-1254.

35. Gilbane AJ, Denton CP, Holmes AM. Scleroderma pathogen-esis: a pivotal role for fibroblasts as effector cells. Arthritis ResTher. 2013;15(3):215.

36. Mayes MD. Scleroderma epidemiology. Rheum Dis Clin NorthAm. 2003;29(2):239-254.

37. Steen VD, Medsger TA. Changes in causes of death in systemicsclerosis, 1972-2002. Ann Rheum Dis. 2007;66(7):940-944.

38. Tyndall AJ, Bannert B, Vonk M, et al. Causes and risk factorsfor death in systemic sclerosis: a study from the EULARScleroderma Trials and Research (EUSTAR) database. AnnRheum Dis. 2010;69(10):1809-1815.

39. Morales-Cardenas A, Perez-Madrid C, Arias L, et al. Pulmo-nary involvement in systemic sclerosis. Autoimmun Rev.2016;15(11):1094-1108.

40. Nikpour M, Baron M. Mortality in systemic sclerosis: lessonslearned from population-based and observational cohortstudies. Curr Opin Rheumatol. 2014;26(2):131-137.

41. Adler S, Huscher D, Siegert E, et al. Systemic sclerosis associ-ated interstitial lung disease - individualized immunosuppres-sive therapy and course of lung function: results of theEUSTAR group. Arthritis Res Ther. 2018;20(1):17.

42. Steen VD, Conte C, Owens GR, Medsger TA Jr. Severerestrictive lung disease in systemic sclerosis. Arthritis Rheum.1994;37(9):1283-1289.

43. Walker UA, Tyndall A, Czirjak L, et al. Clinical risk assessmentof organ manifestations in systemic sclerosis: a report from the






EULAR Scleroderma Trials And Research group database. AnnRheum Dis. 2007;66(6):754-763.

44. Steen VD, Lucas M, Fertig N, Medsger TA Jr. Pulmonary arte-rial hypertension and severe pulmonary fibrosis in systemicsclerosis patients with a nucleolar antibody. J Rheumatol.2007;34(11):2230-2235.

45. Winstone TA, Assayag D, Wilcox PG, et al. Predictors ofmortality and progression in scleroderma-associated intersti-tial lung disease: a systematic review. Chest. 2014;146(2):422-436.

46. Morisset J, Vittinghoff E, Elicker BM, et al. Mortality risk predic-tion in scleroderma-related interstitial lung disease: the SADLmodel. Chest. 2017;152(5):999-1007.

47. Ryerson CJ, Vittinghoff E, Ley B, et al. Predicting survival acrosschronic interstitial lung disease: the ILD-GAP model. Chest.2014;145(4):723-728.

48. Tashkin DP, Elashoff R, Clements PJ, et al. Cyclophosphamideversus placebo in scleroderma lung disease. N Engl J Med.2006;354(25):2655-2666.

49. Tashkin DP, Roth MD, Clements PJ, et al. Mycophenolatemofetil versus oral cyclophosphamide in scleroderma-relatedinterstitial lung disease (SLS II): a randomised controlled,double-blind, parallel group trial. Lancet Respir Med. 2016;4(9):708-719.

50. Fischer A, Brown KK, Du Bois RM, et al. Mycophenolate mofe-til improves lung function in connective tissue disease-associated interstitial lung disease. J Rheumatol. 2013;40(5):640-646.

51. Steen VD, Medsger TA Jr. Case-control study of corticoste-roids and other drugs that either precipitate or protect fromthe development of scleroderma renal crisis. Arthritis Rheum.1998;41(9):1613-1619.

52. Bongartz T, Nannini C, Medina-Velasquez YF, et al. Incidenceand mortality of interstitial lung disease in rheumatoid arthritis:a population-based study. Arthritis Rheum. 2010;62(6):1583-1591.

53. Olson AL, Swigris JJ, Sprunger DB, et al. Rheumatoid arthritis-interstitial lung disease-associated mortality. Am J Respir CritCare Med. 2011;183(3):372-378.

54. Zhang Y, Li H, Wu N, Dong X, Zheng Y. Retrospective studyof the clinical characteristics and risk factors of rheumatoidarthritis-associated interstitial lung disease. Clin Rheumatol.2017;36(4):817-823.

55. Atkins SR, Turesson C, Myers JL, et al. Morphologic and quan-titative assessment of CD20þ B cell infiltrates in rheumatoidarthritis-associated nonspecific interstitial pneumoniaand usual interstitial pneumonia. Arthritis Rheum. 2006;54(2):635-641.

56. Demoruelle MK, Deane KD, Holers VM. When and wheredoes inflammation begin in rheumatoid arthritis? Curr OpinRheumatol. 2014;26(1):64-71.

57. Hyldgaard C, Hilberg O, Pedersen AB, et al. A population-based cohort study of rheumatoid arthritis-associated intersti-tial lung disease: comorbidity and mortality. Ann Rheum Dis.2017;76(10):1700-1706.

58. Kim D, Cho SK, Choi CB, et al. Impact of interstitial lung dis-ease on mortality of patients with rheumatoid arthritis. Rheu-matol Int. 2017;37(10):1735-1745.

59. Jani M, Hirani N, Matteson EL, Dixon WG. The safety of bio-logic therapies in RA-associated interstitial lung disease. NatRev Rheumatol. 2014;10(5):284-294.

60. ClinicalTrials.gov. Phase ll study of pirfenidone in patients withRAILD (TRAIL1). https://clinicaltrials.gov/ct2/show/NCT02808871. Accessed March 12, 2018.

61. Inoue T, Kanayama Y, Ohe A, et al. Immunopathologic studiesof pneumonitis in systemic lupus erythematosus. Ann InternMed. 1979;91(1):30-34.

62. Martinez-Martinez MU, Abud-Mendoza C. Predictors of mor-tality in diffuse alveolar haemorrhage associated with systemiclupus erythematosus. Lupus. 2011;20(6):568-574.



63. Flament T, Bigot A, Chaigne B, Henique H, Diot E, Marchand-Adam S. Pulmonary manifestations of Sjogren’s syndrome. EurRespir Rev. 2016;25(140):110-123.

64. Henderson LA, Loring SH, Gill RR, et al. Shrinking lung syndromeas a manifestation of pleuritis: a newmodel based on pulmonaryphysiological studies. J Rheumatol. 2013;40(3):273-281.

65. Kanakis MA, Kapsimali V, Vaiopoulos AG, Vaiopoulos GA,Samarkos M. The lung in the spectrum of antiphospholipidsyndrome. Clin Exp Rheumatol. 2013;31(3):452-457.

66. Andrade C, Mendonca T, Farinha F, et al. Alveolar hemor-rhage in systemic lupus erythematosus: a cohort review. Lupus.2016;25(1):75-80.

67. Ryu JH, Myers JL, Swensen SJ. Bronchiolar disorders. Am JRespir Crit Care Med. 2003;168(11):1277-1292.

68. Yachoui R, Leon C, Sitwala K, Kreidy M. Pulmonary MALTlymphoma in patients with Sjogren’s syndrome. Clin MedRes. 2017;15(1-2):6-12.

69. Baqir M, Kluka EM, Aubry MC, et al. Amyloid-associated cysticlung disease in primary Sjogren’s syndrome. Respir Med. 2013;107(4):616-621.

70. Nocturne G, Virone A, NgWF, et al. Rheumatoid factor and dis-ease activity are independent predictors of lymphoma in primarySjogren’s syndrome. Arthritis Rheumatol. 2016;68(4):977-985.

71. Connors GR, Christopher-Stine L, Oddis CV, Danoff SK.Interstitial lung disease associated with the idiopathic inflam-matory myopathies: what progress has been made in thepast 35 years? Chest. 2010;138(6):1464-1474.

72. Kang EH, Lee EB, Shin KC, et al. Interstitial lung disease in patientswith polymyositis, dermatomyositis and amyopathic dermato-myositis. Rheumatology (Oxford). 2005;44(10):1282-1286.

73. Grau JM, Miro O, Pedrol E, et al. Interstitial lung disease relatedto dermatomyositis: comparative study with patients withoutlung involvement. J Rheumatol. 1996;23(11):1921-1926.

74. Stone KB, Oddis CV, Fertig N, et al. Anti-Jo-1 antibody levelscorrelate with disease activity in idiopathic inflammatorymyopathy. Arthritis Rheum. 2007;56(9):3125-3131.

75. Satoh M, Tanaka S, Ceribelli A, Calise SJ, Chan EK.A comprehensive overview on myositis-specific antibodies:new and old biomarkers in idiopathic inflammatory myopathy.Clin Rev Allergy Immunol. 2017;52(1):1-19.

76. Solomon J, Swigris JJ, Brown KK. Myositis-related interstitiallung disease and antisynthetase syndrome. J Bras Pneumol.2011;37(1):100-109.

77. Hallowell RW, Danoff SK. Interstitial lung disease associatedwith the idiopathic inflammatory myopathies and the antisyn-thetase syndrome: recent advances. Curr Opin Rheumatol.2014;26(6):684-689.

78. Hervier B, Wallaert B, Hachulla E, et al. Clinical manifestationsof anti-synthetase syndrome positive for anti-alanyl-tRNA syn-thetase (anti-PL12) antibodies: a retrospective study of 17cases. Rheumatology (Oxford). 2010;49(5):972-976.

79. Hamaguchi Y, Fujimoto M, Matsushita T, et al. Common anddistinct clinical features in adult patients with anti-aminoacyl-tRNA synthetase antibodies: heterogeneity within the syn-drome. PLoS One. 2013;8(4):e60442.

80. Johnson C, Connors GR, Oaks J, et al. Clinical and pathologicdifferences in interstitial lung disease based on antisynthetaseantibody type. Respir Med. 2014;108(10):1542-1548.

81. Kalluri M, Sahn SA, Oddis CV, et al. Clinical profile of anti-PL-12 autoantibody: cohort study and review of the literature.Chest. 2009;135(6):1550-1556.

82. Hervier B, Uzunhan Y, Hachulla E, et al. Antisynthetase syn-drome positive for anti-threonyl-tRNA synthetase (anti-PL7)antibodies. Eur Respir J. 2011;37(3):714-717.

83. Schneider F, Yousem SA, Bi D, Gibson KF, Oddis CV,Aggarwal R. Pulmonary pathologic manifestations of anti-glycyl-tRNA synthetase (anti-EJ)-related inflammatory myop-athy. J Clin Pathol. 2014;67(8):678-683.

84. Cavagna L, Caporali R, Abdi-Ali L, Dore R, Meloni F,Montecucco C. Cyclosporine in anti-Jo1-positive patients

0.1016/j.mayocp.2018.09.002 323


https://clinicaltrials.gov/ct2/show/NCT02808871

https://clinicaltrials.gov/ct2/show/NCT02808871




324

Dow

with corticosteroid-refractory interstitial lung disease.J Rheumatol. 2013;40(4):484-492.

85. Labirua-Iturburu A, Selva-O’Callaghan A, Martinez-Gomez X,Trallero-Araguas E, Labrador-Horrillo M, Vilardell-Tarres M.Calcineurin inhibitors in a cohort of patients withantisynthetase-associated interstitial lung disease. Clin ExpRheumatol. 2013;31(3):436-439.

86. Doyle TJ, Dhillon N, Madan R, et al. Rituximab in the treat-ment of interstitial lung disease associated with antisynthetasesyndrome: a multicenter retrospective case review.J Rheumatol. 2018;45(6):841-850.

87. Lally L, Spiera RF. Pulmonary vasculitis. Rheum Dis Clin NorthAm. 2015;41(2):315-331.

88. Comarmond C, Crestani B, Tazi A, et al. Pulmonary fibrosis inantineutrophil cytoplasmic antibodies (ANCA)-associatedvasculitis: a series of 49 patients and review of the literature.Medicine (Baltimore). 2014;93(24):340-349.

89. Hervier B, Pagnoux C, Agard C, et al. Pulmonary fibrosis asso-ciated with ANCA-positive vasculitides: retrospective study of12 cases and review of the literature. Ann Rheum Dis. 2009;68(3):404-407.

90. Ando Y, Okada F, Matsumoto S, Mori H. Thoracic manifesta-tion of myeloperoxidase-antineutrophil cytoplasmic antibody(MPO-ANCA)-related disease: CT findings in 51 patients.J Comput Assist Tomogr. 2004;28(5):710-716.

91. Homma S, Matsushita H, Nakata K. Pulmonary fibrosis in mye-loperoxidase antineutrophil cytoplasmic antibody-associatedvasculitides. Respirology. 2004;9(2):190-196.

92. Foulon G, Delaval P, Valeyre D, et al. ANCA-associated lungfibrosis: analysis of 17 patients. Respir Med. 2008;102(10):1392-1398.

93. Hosoda C, Baba T, Hagiwara E, et al. Clinical features of usualinterstitial pneumonia with anti-neutrophil cytoplasmic anti-body in comparison with idiopathic pulmonary fibrosis. Respir-ology. 2016;21(5):920-926.

94. Abril A, Kwon M, Rojas C, Khoor A, Mira-Avendano I.SAT0519: interstitial lung disease in ANCA associated vascul-tis patients: comparison with idiopathic fibrosis and interstitialpneumonia with autoimmune features. Ann Rheum Dis. 2018;77(suppl 2):1115.

95. Tzelepis GE, Kokosi M, Tzioufas A, et al. Prevalence andoutcome of pulmonary fibrosis in microscopic polyangiitis.Eur Respir J. 2010;36(1):116-121.

96. Fischer A, Lee JS, Cottin V. Interstitial lung disease evaluation:detecting connective tissue disease. Respiration. 2015;90(3):177-184.

97. Fujita J, Ohtsuki Y, Yoshinouchi T, et al. Idiopathic non-specificinterstitial pneumonia: as an “autoimmune interstitial pneu-monia”. Respir Med. 2005;99(2):234-240.

98. Kinder BW, Collard HR, Koth L, et al. Idiopathic nonspecificinterstitial pneumonia: lung manifestation of undifferentiatedconnective tissue disease? Am J Respir Crit Care Med. 2007;176(7):691-697.

99. Solomon JJ, Chartrand S, Fischer A. Current approach to con-nective tissue disease-associated interstitial lung disease. CurrOpin Pulm Med. 2014;20(5):449-456.

100. Corte TJ, Copley SJ, Desai SR, et al. Significance of connectivetissue disease features in idiopathic interstitial pneumonia. EurRespir J. 2012;39(3):661-668.

101. Vij R, Noth I, Strek ME. Autoimmune-featured interstitial lungdisease: a distinct entity. Chest. 2011;140(5):1292-1299.

102. Assayag D, Kim EJ, Elicker BM, et al. Survival in interstitial pneu-monia with features of autoimmune disease: a comparison ofproposed criteria. Respir Med. 2015;109(10):1326-1331.

103. Dai J, Wang L, Yan X, et al. Clinical features, risk factors, andoutcomes of patients with interstitial pneumonia with autoim-mune features: a population-based study. Clin Rheumatol.2018;37(8):2125-2132.

104. Yoshimura K, Kono M, Enomoto Y, et al. Distinctive character-istics and prognostic significance of interstitial pneumonia with



autoimmune features in patients with chronic fibrosing inter-stitial pneumonia. Respir Med. 2018;137:167-175.

105. Ahmad K, Barba T, Gamondes D, et al. Interstitial pneumoniawith autoimmune features: clinical, radiologic, and histologicalcharacteristics and outcome in a series of 57 patients. RespirMed. 2017;123:56-62.

106. Chartrand S, Swigris JJ, Stanchev L, Lee JS, Brown KK,Fischer A. Clinical features and natural history of interstitialpneumonia with autoimmune features: a single center experi-ence. Respir Med. 2016;119:150-154.

107. Oldham JM, Adegunsoye A, Valenzi E, et al. Characterisationof patients with interstitial pneumonia with autoimmune fea-tures. Eur Respir J. 2016;47(6):1767-1775.

108. Jee AS, Bleasel JF, Adelstein S, Keir GJ, Corte TJ. A call for unifor-mity in implementing the IPAF (interstitial pneumonia with auto-immune features) criteria. Eur Respir J. 2016;48(6):1811-1813.

109. Jee AS, Adelstein S, Bleasel J, et al. Role of autoantibodies inthe diagnosis of connective-tissue disease ILD (CTD-ILD)and interstitial pneumonia with autoimmune features (IPAF).J Clin Med. 2017;6(5):E51.

110. Chartrand S, Lee JS, Fischer A. Longitudinal assessment ofinterstitial pneumonia with autoimmune features is encour-aged. Respir Med. 2017;132:267.

111. Badesch DB, Raskob GE, Elliott CG, et al. Pulmonary arterialhypertension: baseline characteristics from the REVEAL Regis-try. Chest. 2010;137(2):376-387.

112. Condliffe R, Howard LS. Connective tissue disease-associatedpulmonary arterial hypertension. F1000Prime Rep. 2015;7:06.

113. Hao Y, Thakkar V, Stevens W, et al. A comparison of the pre-dictive accuracy of three screening models for pulmonaryarterial hypertension in systemic sclerosis. Arthritis Res Ther.2015;17:7.

114. Pagan RJ, Lee AS, Austin CO, Burger CD. Screening for con-nective tissue disease in pulmonary arterial hypertension. SouthMed J. 2014;107(10):666-669.

115. Pulmonary Hypertension Association. PH care centers: find aPH care center. https://phassociation.org/phcarecenters/accredited-centers. Accessed March 12, 2018.

116. Tselios K, Gladman DD, Urowitz MB. Systemic lupus erythe-matosus and pulmonary arterial hypertension: links, risks, andmanagement strategies. Open Access Rheumatol. 2017;9:1-9.

117. Coghlan JG, Galie N, Barbera JA, et al. Initial combination ther-apy with ambrisentan and tadalafil in connective tissuedisease-associated pulmonary arterial hypertension (CTD-PAH): subgroup analysis from the AMBITION trial. AnnRheum Dis. 2017;76(7):1219-1227.

118. Burger CD, Long PK, Shah MR, et al. Characterization of first-time hospitalizations in patients with newly diagnosed pulmo-nary arterial hypertension in the REVEAL registry. Chest. 2014;146(5):1263-1273.

119. Galie N, Humbert M, Vachiery JL, et al. 2015 ESC/ERS Guide-lines for the diagnosis and treatment of pulmonary hyperten-sion: the Joint Task Force for the Diagnosis and Treatment ofPulmonary Hypertension of the European Society of Cardiol-ogy (ESC) and the European Respiratory Society (ERS):Endorsed by: Association for European Paediatric andCongenital Cardiology (AEPC), International Society for Heartand Lung Transplantation (ISHLT). Eur Heart J. 2016;37(1):67-119.

120. Rhee RL, Gabler NB, Sangani S, Praestgaard A, Merkel PA,Kawut SM. Comparison of treatment response in idiopathicand connective tissue disease-associated pulmonary arterialhypertension. Am J Respir Crit Care Med. 2015;192(9):1111-1117.

121. Zisman DA, Schwarz M, et al. Idiopathic Pulmonary FibrosisClinical Research Network. A controlled trial of sildenafil inadvanced idiopathic pulmonary fibrosis. N Engl J Med. 2010;363(7):620-628.

122. King TE Jr, Behr J, Brown KK, et al. BUILD-1: a random-ized placebo-controlled trial of bosentan in idiopathic



https://phassociation.org/phcarecenters/accredited-centers

https://phassociation.org/phcarecenters/accredited-centers




pulmonary fibrosis. Am J Respir Crit Care Med. 2008;177(1):75-81.

123. Raghu G, Million-Rousseau R, Morganti A, Perchenet L,Behr J; MUSIC Study Group. Macitentan for the treatmentof idiopathic pulmonary fibrosis: the randomisedcontrolled MUSIC trial. Eur Respir J. 2013;42(6):1622-1632.

124. Chung L, Liu J, Parsons L, et al. Characterization of connectivetissue disease-associated pulmonary arterial hypertensionfrom REVEAL: identifying systemic sclerosis as a uniquephenotype. Chest. 2010;138(6):1383-1394.



125. Hachulla E, Jais X, Cinquetti G, et al. Pulmonary arterial hyper-tension associated with systemic lupus erythematosus: resultsfrom the French Pulmonary Hypertension Registry. Chest.2018;153(1):143-151.

126. Chung L, Farber HW, Benza R, et al. Unique predictors ofmortality in patients with pulmonary arterial hypertensionassociated with systemic sclerosis in the REVEAL registry.Chest. 2014;146(6):1494-1504.

127. Austin C, Burger C, Kane G, et al. High-risk echocardiographicfeatures predict mortality in pulmonary arterial hypertension.Am Heart J. 2017;189:167-176.

0.1016/j.mayocp.2018.09.002 325




Interstitial Lung Disease and Other Pulmonary Manifestations in … · 2019-09-10 · Lung...

Documents

Transcript of Interstitial Lung Disease and Other Pulmonary Manifestations in … · 2019-09-10 · Lung...