|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 2 | Page : 208-209
Anti-synthetase syndrome masquerading as COVID-19
Rajat Kharbanda1, Neeraj Jain2, Latika Gupta3
1 Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Radiodiagnosis, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Rheumatology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton; City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham; Division of Musculoskeletal and Dermatological Sciences, Centre for Musculoskeletal Research, School of Biological Sciences, The University of Manchester, Manchester, UK
|Date of Submission||14-Aug-2021|
|Date of Acceptance||26-Aug-2021|
|Date of Web Publication||03-May-2022|
Dr. Latika Gupta
Department of Rheumatology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, WV10 0QP
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kharbanda R, Jain N, Gupta L. Anti-synthetase syndrome masquerading as COVID-19. Indian J Rheumatol 2022;17:208-9
A 31-year-old gentleman presented with 8 months of dyspnea on exertion, fever, inflammatory polyarthritis, and myalgia. Three months into the illness, COVID-19 pneumonia was suspected based on bilateral basal ground-glass opacities (GGOs) on thoracic imaging with Computerised Tomography (CT) score of 9/25. However, COVID-19 reverse transcription–polymerase chain reaction tested negative on several occasions. With the initiation of steroids, some improvement in shortness of breath was noted, with reappearance of symptoms on discontinuation [Figure 1]a. A repeat CT at this juncture suggested worsened ground glassing, with a CT score of 12/25 though COVID-19 RTPCT still tested negative [Figure 1]c.
|Figure 1: (a) Timeline of the patient clinical manifestations, investigations along with treatment. (b) Bilateral fibro-atelectatic bands and basal ground-glass opacities with subpleural sparing (black arrow). (c) Repeat CT (3 months later) showing progression of parenchymal opacities with subpleural sparing (black arrow)|
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He reported to rheumatology department 8 months into the illness when on physical examination, grade 2 clubbing was present, and fine inspiratory crackles were evident in lower lung fields. Small hand joints were tender and manual muscle testing score was 76/80. A diagnosis of anti-synthetase syndrome was suspected. Muscle enzymes were normal. Antinuclear antibodies were positive (4+ cytoplasmic) and myositis-specific antibodies tested positive for Ro52 and PL-12. Pulmonary function tests showed a restrictive pattern of decreased lung function (forced vital capacity: 39%, forced expiratory volume in 1 s: 43).
GGOs of autoimmune origin may be confused with COVID-19 pneumonia in the midst of a raging pandemic. Insidious onset and other rheumatic manifestations may be salient pointers to an alternative diagnosis. This patient did not exhibit classic cutaneous features such as Gottron's or heliotrope rashes or mechanic's hands. Subpleural sparing and progression of CT findings over a span of 3 months favored nonspecific interstitial pneumonia (NSIP) interstitial lung disease [Figure 1]b and [Figure 1]c in this unique case.
COVID-19 typically manifests as peripheral GGOs that may progress into patchy areas of consolidation and subsequent fibrosis depending on disease severity. In contrast, GGO may occur in ASSD-related NSIP as well. The subpleural lung zones are typically spared and the absence of parenchymal consolidation is further suggestive. Symptoms of dyspnea, fever, and myalgia during the COVID-19 pandemic may pose a diagnostic challenge. Therefore, it is imperative to educate practitioners about discriminating features between viral pneumonias with those of autoimmune origin.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Saud A, Naveen R, Aggarwal R, Gupta L. COVID-19 and myositis: What we know so far. Curr Rheumatol Rep 2021;23:63.
Wang Y, Dong C, Hu Y, Li C, Ren Q, Zhang X, et al.
Temporal changes of CT findings in 90 patients with COVID-19 pneumonia: A longitudinal study. Radiology 2020;296:E55-64.
Silva CI, Müller NL, Lynch DA, Curran-Everett D, Brown KK, Lee KS, et al.
Chronic hypersensitivity pneumonitis: Differentiation from idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia by using thin-section CT. Radiology 2008;246:288-97.