Case-report: Organizing pneumonia in a pregnant woman with rheumatoid arthritis during COVID-19 pandemic

Cornillie, A.; Grivegnee, C.

Introduction Rheumatoid arthritis (RA) is a systemic inflammatory disease characterized by destructive polyarthritis and extra-articular organ involvement. Lungs are one of the most commonly affected organ in RA, and the lung involvement in RA results in a various clinical features including interstitial lung disease (ILD) and organizing pneumonia (OP). OP is a histologic term characterized by the presence of buds of granulation tissue in bronchioles and alveoli. OP can be either idiopathic (cryptogenic organizing pneumonia) or secondary to underlying disease such as infection, drugs or connective tissue disease including RA. Lung biopsy is usually recommended for the diagnosis, but the following criteria fulfilled by patients can lead to the diagnosis: (1) specific radiological manifestations (nonsegmental randomized consolidation with/without ground grass opacities in chest CT), (2) no causative infectious agent, (3) no response to antibiotics and (4) good response to corticosteroid therapy. We describe here the case of organized pneumonia discovered in a pregnant woman with known rheumatoid arthritis during COVID-19 pandemic. Case description A 39-year old moroccan woman, gravida 4, para 1, was admitted during COVID-19 pandemic at 30 weeks' gestation to maternity hospital with a 1-week history of cough, dyspnea and fever. Her medical history included rheumatoid arthritis and gestational diabetes. She was treated with 5mg of prednisolone daily for her RA. Blood sample showed white blood cell count and C reactive protein at a level of 6860/mm3 and 42mg/L respectively. Chest CT performed at her admission revealed diffuse irregular nodular condensations associated with ground glass infiltrates and a right lower lobe parenchymal condensation with airbronchogram in favor of superinfection. Given circumstances, she was tested twice for SARS-Cov-2 48 hours apart by PCR on nasopharyngeal sample and results came back negative. She was treated empirically with ceftriaxone and azithromycin during the first week and described an improvement in her clinical condition but symptoms reappeared 4 days after stopping treatment. During the 2 following months, until the delivery, the patient remained subpyretic with a nonproductive cough and moderate dyspnea. 5 days after the delivery, duesimilar image findings but some of the irregular nodular condensations showed a reversed halo sign and had a migrating character. Considering this typical image findings, the absence of causative infectious agents (excluded by bronchoalveaolar lavage performed after delivery) and the absence of response to antibiotics, we concluded with a diagnosis of OP secondary to RA without performing lung biopsy samples. A treatment with 48mg of methylprednisolone (and 100mg of azathioprine a few weeks later) was initiated. One month later, she showed a spectacular improvement in her clinical condition. A new chest CT highlighted disappearance of the majority of the ground glass areas and of all the condensations previously described. Methylprednisolone was then progressively tapered. Conclusion OP is a common pulmonary complication that can develop in RA. However, despite ou research, we have not found any other clinical case describing this disorder during pregnancy with RA. Since OP is a non-specific inflammatory response to an aggression of the organism, could we consider that the pregnancy is a state of aggression capable of causing such a response In addition, this clinical case illustrates the diagnostic challenge of this pathology during the Covid-19 pandemic.