[The 456th case: polyarthritis, dry cough, dyspnea on exertion]

A 53-year-old woman presented with arthralgia and dyspepsia on exertion.Symmetrical joint swelling and pain of bilateral hands with pigmentation sedimentation in the articular surfaces, dry cough and short of breath were the main clinical manifestations.Elevated levels of erythrocyte sedimentation rate(89 mm/1 h), C-reactive protein (64.45 mg/L), IgG(31.22 g/L) and IgA (5.44 g/L). Rheumatoid factor was positive and anti-cyclic citrullinated peptide antibody was negative.Chest high-resolution computed tomography scan found that diffusely distributed lung nodules, round cysts with varying sizes and patchy ground glass opacities.A significant plasma cell infiltration and amyloid deposition were seen in lung tissue.The patient was finally diagnosed as rheumatoid arthritis, interstitial lung disease and pulmonary nodules.Combination therapy of prednisone 7.5 mg qodpo, thalidomide 50 mg qdpo, tocilizumab 560 mg iv once per month for 1 month.Chest computed tomography showed stable lung nodules, however, pulmonary interstitial lesions gradually aggravated.