Reversed halo sign in organizing pneumonia secondary to rheumatoid arthritis.

A 79-year-old non-smoker woman was admitted to our hospital following 15 days of unproductive coughing, moderate fever (38°C) and asthenia. She was diagnosed with rheumatoid arthritis five years before; the dia gnosis was made based on the presence of morning stiffness, symmetric joint pain and swelling in fingers, wrists, elbows, and ankles, and a positivity for both rheumatoid factor (1/160) and anti-cyclic citrullinated peptide antibodies (52.4 U/ml); disease activity was high (disease activity score [DAS]-28 was 5.4). How ever, radiograph showed the absence of bone erosions. In addition, health assessment questionnaire (HAQ) score was 1. Therefore, the woman started treatment with hydroxychloroquine 400 mg daily, and methyprednisolone 8 mg daily. After 12 weeks of treatment, disease activity was moderate (DAS-28 was 3.8). However, the woman complained of frequent episodes of headaches during the last weeks; this was considered as an adverse effect of the hydroxychloroquine, and therefore the dose was tapered to 200 mg daily; within six months, the patient achieved stable low disease activity (DAS-28 was 2.8), HAQ score was 0, and radiograph confirmed the absence of bone erosions. Hydroxy chloroquine 200 mg daily was continued, and methyprednisolone was tapered to 4 mg daily. At the time of the admission to our ward, the patient was under trea tment with hydroxychloroquine 200 mg daily, and me thyprednisolone 4mg daily. Physical examination revealed inspiratory crackles at both lung bases. Articular examination showed no joint swelling/pain except for both wrists. Arterial blood gas values were the following: pH 7.45, pO2 69 mmHg, pCO2 34 mmHg, SO2 94%. White blood count was in the normal range, C-reactive protein was 103 mg/dl and erythrocyte sedimentation rate was 60 mm/h. Biochemical variables were unremarkable. Chest x-ray showed bilateral Mario F Damiani1, Pierluigi Carratù1, Vitaliano N Quaranta1, Valentina A Ventura1, Carlo Florio2, Onofrio Resta1