Rheumatoid Arthritis Related Interstitial Lung Disease- Efficacy of Treatment with Intravenous Tocilizumab after Development of Bilateral Lung Thickening- Case Report with 24 Month Follow-Up

Background: The involvement of lung in course of rheumatoid arthritis is very common and is often associated with a poor prognosis. ILD (Interstitial Lung Disease) is often considered as a smoking or drug induced disease, caused by some DMARDs or anti-TNF drugs. Tocilizumab (TCZ) is a biologic agent approved for the treatment of RA. Case Report: a man, smoker of cigarettes, affected by active and aggressive RA, was treated with Methotrexate (MTX) and low-dose Glucocorticoids (GC) with a good result until he developed a clinical ILD. A higher dose of GC, Azathioprine and Cyclosporin A were not able to get the disease on remission. Therefore we treated the patient with IV monthly TCZ, which suddenly induced the remission of the arthritis, while ILD became more and more severe. The patient was admitted to a Pneumology Unit because of bilateral bronchopneumonia with respiratory failure.TCZ therapy was stopped while respiratory disease reached the complete remission, contrary RA became more and more disabling. Therefore we treated him once more with IV TCZ, reaching the complete remission of RA and ILD. A second minor episode of left pneumonia occurred after further 12 months of therapy with TCZ. The treatment with TCZ was successfully continued after a brief interruption. 24 months of follow-up show that in this patient TCZ is effective on RA and that the flares of the Ra-related ILD become less severe while therapy with TCZ is continued. This case suggests that TCZ, contrary to other drugs, in not contraindicated in the treatment of RA-related ILD.