An 81-year-old woman presented to the rheumatology department with a relapse of her longstanding seropositive erosive rheumatoid arthritis (RA). Her medical history included chronic lymphocytic leukemia (CLL) with slowly progressing lymphadenopathy, for which she had recently declined treatment, opting instead for active monitoring. A baseline chest X-ray (CXR) was conducted in anticipation of initiating methotrexate therapy, revealing incidental subtle basal interstitial changes. However, she reported no respiratory symptoms, B symptoms, or recent infections, and no organomegaly was detected on examination. Pulmonary function tests, including spirometry, lung volumes, and gas transfer factors, were within normal limits. Her lymphocyte count remained stable but elevated at 25–30 ×109 /L, with a reference range of 1–4 ×109 /L, over the preceding 6 years.
A subsequent high-resolution CT (HRCT) scan revealed pulmonary nodular opacities, mediastinal and axillary lymphadenopathy, and mild splenomegaly (Figure 1). The case was referred to the interstitial lung disease multidisciplinary team meeting (ILD-MDT) for further evaluation.
