January 2025 Medical Image of the Month: Psoriasis with Pulmonary Involvement

Figure 1. Axial lung-windowed CT reconstructions through the mid (A,B) and lower (C) lungs from a 58-year-old man with psoriasis presenting for evaluation of interstitial lung disease.  There is peripheral and lower lung predominant reticulation, ground glass, and traction bronchiolectasis with architectural distortion and atelectasis. To view Figure 1 in a separate enlarged window click here.  

Figure 2. Low-power (A) and high-power (B,C) hematoxylin & eosin-stained pathology slides from a surgical lung biopsy (left lower lobe) demonstrating scattered lymphoid aggregates with patchy granulomatous organizing pneumonia and scattered loosely formed nonnecrotizing granulomas, concern for underlying systemic connective tissue disease-related interstitial lung disease. To view Figure 2 in a separate enlarged window click here.

A 58-year-old man presented to our pulmonary service for a second opinion concerning his interstitial lung disease (ILD), which had been diagnosed as rheumatoid arthritis associated ILD. The patient had a positive rheumatoid factor (barely) at an outside institution, but no other test results or historical or physical exam findings to suggest rheumatoid arthritis. He was being treated with mycophenolate, but did not feel that he was improving. To the contrary, there had been a recent decline in his overall lung function. The only other relevant medical history is psoriasis. The patient is a lifelong nonsmoker. Resting pulse oximetry was 95% on room air with a brief desaturation to 88% during ambulation, which quickly recovered with rest. The patient’s vital signs were otherwise normal. Physical exam findings were normal aside from mild cutaneous findings of plaque psoriasis. Results from pulmonary function testing at an outside institution were available, revealing a forced vital capacity 40% of reference and DLCO 37% of reference. The overall picture was consistent with restrictive lung disease. Images from an outside CT (Figure 1) demonstrated patchy findings of ILD with peripheral and lower lobe predominant reticulation, ground glass, and architectural distortion without any significant honeycombing or air trapping. The pattern was felt to be pretty nonspecific, but most consistent with ILD in the setting of autoimmune disease, favoring an NSIP or OP pattern over UIP.

Slides from the patient’s outside surgical lung biopsy were reviewed by our pathology department, who have expertise regarding pulmonary manifestations of psoriasis (1). Pathology (Figure 2) showed randomly distributed lymphoid aggregates in association with mild patchy chronic inflammatory infiltrates and patchy areas of numerous macrophages filling airspaces. There were scattered foci of organizing pneumonia focally with nonnecrotizing granulomas. In addition, there were a few scattered very loosely formed nonnecrotizing granulomas. Rare eosinophils were also present. Rare foci of osseous metaplasia were also identified.  While the findings were felt to be nonspecific, they are most concerning for an underlying systemic connective tissue disease involving the lung. The case was discussed at our multidisciplinary ILD conference and a consensus diagnosis of ILD related to psoriasis was made. There is limited data suggesting possible improvement in psoriatic ILD with psoriasis treatment using secukinumab (2). However, there are also reports of secukinumab exacerbating ILD in the setting of psoriasis (3). Given the patient’s lack of improvement on mycophenolate, a trial of secukinumab is being considered.

Interstitial pneumonia is relatively rare in the setting of psoriasis, with a series of 392 psoriasis patients demonstrating an incidence of 2% (4). In this series, the most common imaging findings were lower lung predominate ground glass and reticulation, as was seen in this case. Interestingly, one case series (5) found that a UIP pattern of fibrosis was the most common pattern of ILD on CT in patients with plaque psoriasis; however, many of these patients were smokers. Concomitant smoking seems to predispose the patient towards a UIP pattern of ILD in the setting of psoriasis. In non-smokers, NSIP and OP patterns of ILD seemed more prevalent. Although rare, ILD in psoriasis is an important possibility to consider given that some patients treated with biologic agents for their psoriasis experienced improvements in their ILD (2,4).

Clint Jokerst, MD1, Yasmeen M. Butt, MD2

Departments of 1Radiology and 2Pathology

Mayo Clinic Arizona

Phoenix, AZ USA

References

1. Butt YM, Smith ML, Tazelaar HD, Roden AC, Mengoli MC, Larsen BT. Surgical Pathology of Diffuse Parenchymal Lung Disease in Patients With Psoriasis or Psoriatic Arthritis. Arch Pathol Lab Med. 2022 May 1;147(5):525-533. [CrossRef][PubMed]

2. Miyachi H, Nakamura Y, Nakamura Y, Matsue H. Improvement of the initial stage of interstitial lung disease during psoriasis treatment with secukinumab. J Dermatol. 2017 Dec;44(12):e328-e329. [CrossRef][PubMed]

3. Kajihara I, Yamada-Kanazawa S, Maeda-Otsuka S, Jinnin M, Akaike K, Ihn H. Secukinumab-induced interstitial pneumonia in a patient with psoriasis vulgaris. J Dermatol. 2017 Dec;44(12):e322-e323. [CrossRef][PubMed]

4. Kawamoto H, Hara H, Minagawa S, Numata T, Araya J, Kaneko Y, Umezawa Y, Asahina A, Nakagawa H, Kuwano K. Interstitial Pneumonia in Psoriasis. Mayo Clin Proc Innov Qual Outcomes. 2018 Sep 20;2(4):370-377. [CrossRef][PubMed]

5. Rizzetto G, Tagliati C, Fogante M, et al. CT Patterns of Interstitial Lung Disease in Patients with Plaque Psoriasis: A Retrospective Case Series Study. Medicina (Kaunas). 2023 Sep 12;59(9):1650. [CrossRef][PubMed]

Cite as: Jokerst C, Butt YM. January 2025 Medical Image of the Month: Psoriasis with Pulmonary Involvement. Southwest J Pulm Crit Care Sleep. 2025;30(1):5-7. doi:

https://doi.org/10.13175/swjpccs054-24

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Medical Image of the Week: Scleroderma

Figure 1. Frontal view of the chest shows shallow lung volumes with reticulation and bronchiolar dilatation, including slightly asymmetric basilar opacity, left greater than right most suggestive of interstitial lung disease.

Figure 2. X-ray of the right hand performed 2 years prior to the chest x-ray reveals distal tuft resorption and erosions in addition to distal subcutaneous calcifications. The finger tips also appear atrophied and tapered.

A 56-year-old man presents with cough and dyspnea. Pertinent history is significant for scleroderma. A complete blood count and differential count were unremarkable. A chest radiograph was obtained (Figure 1). Based on overall imaging and clinical history, the chest x-ray findings are highly suggest interstitial lung disease likely related to scleroderma and a recommendation for high resolution chest CT was made.

Progressive systemic sclerosis (scleroderma) is an autoimmune connective tissue disease that affects 30-50 year old women more often than men and is characterized by the overproduction of collagen which can lead to fibrosis which includes the lungs, skin, and may also affect visceral organs (1). In the hands, vasculitis and Raynaud's phenomenon may lead to distal tapering (2). Although acro-osteolysis or distal tuft resorption can be seen in a wide variety of disorders, it may be present in up to 80% of patients with scleroderma. High-resolution chest CT is helpful to characterize the degree of involvement and fibrosis which tends to be basilar and peripherally predominant and may include both usual interstitial pneumonia or nonspecific interstitial pneumonitis as common patterns.

Veronica A. Arteaga MD and Kenneth S. Knox MD

Departments of Medical Imaging and Pulmonary and Critical Care

University of Arizona Medical Center

Tucson, Arizona

References

1. Mayberry JP, Primack SL, Müller NL. Thoracic manifestations of systemic autoimmune diseases: radiographic and high-resolution CT findings. Radiographics. 2000;20(6):1623-35. [CrossRef] [PubMed]
2. Manaster BJ, May DA, Disler DG. Musculoskeletal Imaging, The Requisites, 4^th edition. Mosby, Elsevier. Chapter 20: Connective Tissue Disorders, pages 288-293.

Reference as: Arteaga VA, Knox KS. Medical image of the week: scleroderma. Southwest J Pulm Crit Care. 2015;10(4):199-200. doi: http://dx.doi.org/10.13175/swjpcc034-15 PDF

Medical Image of the Week: CREST plus ILD

Figure 1. Illustrations of CREST syndrome (see below).

A 60 year old female with a history of fibromyalgia presented with dyspnea and skin changes, predominantly on the hands.  Physical exam and imaging showed classic findings of limited cutaneous systemic sclerosis (scleroderma) CREST syndrome.  Calcinosis cutis (Figure 1A), Raynaud’s (not shown but endorsed by the patient), Esophageal dysmotility (Figure 1B, dilated esophagus), Sclerodactyly (Figure 1C), and Teleganectasias (Figure 1D) were all present.  Ground glass opacities were seen predominantly in the bilateral lower lung zones, associated with increased reticular markings (Figure 2A), and traction bronchiectasis (Figure 2B). 

Figure 2. Representative images from the patient’s CT scan showing pulmonary involvement.

Pulmonary involvement is noted in the majority of scleroderma patients.  Interstitial lung disease (ILD) is common and often portends a poor prognosis.

Isabel Oliva, MD and Ken Knox, MD

Division of Thoracic Imaging and Pulmonary & Critical Care Medicine

Interstitial Lung Disease Program

Reference as: Oliva I, Knox K. Medical image of the week: CREST plus ILD. Southwest J Pulm Crit Care. 2013;6(6):275-6. PDF