Shortness of Breath

Try out this rheumatology case and test your clinical knowledge. The answers are at the bottom.


A 74-year-old woman presents to A&E with a 3-month history of persistent shortness of breath. She mentions that she used to be able to comfortably walk a mile to the shops but has now become even more breathless.

Rheumatoid Arthritis

SpO2: 92%
Temperature: 36.9
BP: 117/82
HR: 73
RR: 24

HS 1+2+0
Fine crepitations in bilateral upper zones

Some initial bloods are taken:

Q1: Which joints are classically affected in rheumatoid arthritis (Bonus – what simple examination maneuver is likely to support this diagnosis?)

An initial CXR is requested:

Image 1: Case courtesy of Dr Ian Bickle, From the case rID: 50303

Q2: Interpret the CXR.

Q3: What are the different causes of upper and lower zone fibrosis?

Q4: What further investigations would support the likely diagnosis?


Reveal the Answers

Answer to Question 1

RA classically symmetrically affects small joints including the AC joint and the small joints in the hand/foot – the MCP/MTP and PIP joints. This is in contrast to OA, which classically asymmetrically affects large axial joints e.g. hip/knee and the CMC and DIP joints in the hand.

RA Hand Signs
OA Hand Signs
Swan-neck deformity (hyperextension of PIP and flexion of DIP)
Heberden node (DIP)
Boutonniere deformity (flexion of PIP and hyperextension of DIP)
Bouchard Node (PIP)
Z-thumb deformity (hyperextension of IP joints and flexion of MCP joint
Ulnar deviation of fingers and wrist
Rheumatoid nodules (Extensor surfaces)

The metacarpal/tarsal squeeze test is a simple test which involves squeezing the MCP joints – a positive test elicits pain and is indicative of RA


Answer to Question 2

The CXR shows bilateral reticular-nodular patterning in both upper zones consistent with bilateral upper zone fibrosis. Also present – pacemaker (single lead)


Answer to Question 3

Upper Zone – CHARTS
Lower Zone – BRAINS
Coal Worker’s pneumonocosis (and any other pneumonocosis)
Hypersensitivity Pneumonitis
Rheumatoid arthritis
Ankylosing spondylosis
Radiation fibrosis
Idiopathic pulmonary fibrosis
Nitrofurantoin (and other drugs e.g. amiodarone, methotrexate, bleomycin)
Systemic Sclerosis

Answer to Question 4

Spirometry would be very useful, and would likely show a restrictive deficit (FEV1/FVC > 0.8 with a reduced TLC but increased RV)

A bronchio-alveolar lavage would also be helpful in ascertaining the cytology of any inflammatory cells in the lung – likely lymphocytic

The gold standard investigation would be a high-resolution CT Chest with contrast (viewed in the lung window) – this would likely show the presence of multiple rheumatoid pulmonary nodules and honeycombing in the upper lobe.

These findings would be consistent with a diagnosis of Caplan’s Syndrome – a form of pneumoconiosis associated with RA (NB – it is less likely to be simply RA-induced fibrosis due to presence of predominantly upper zone fibrosis)

To get more information about the conditions mentioned in this case including diagnosis and management, have a look at our free haematology notes on In2Med. Written by medical students, we have pitched them just at the right level to help you ace your exams.

Dr Amol Joshi
University of Cambridge

About The Author

This case is written by Dr Amol Joshi who has an interest in writing medical puzzles.