Adult Acute Respiratory Distress Syndrome (ARDS) Caused by Human Rhinovirus During Janus Kinase Inhibitor Therapy for Rheumatoid Arthritis: A Case Report and Literature Review

An adult with seropositive rheumatoid arthritis (RA) receiving methotrexate (MTX) and tofacitinib, a Janus kinase (JAK) inhibitor, developed rapidly progressive hypoxemic respiratory failure following a brief coryzal prodrome. High-resolution CT showed diffuse bilateral ground-glass opacities with dependent consolidation. An upper-airway syndromic multiplex PCR detected human rhinovirus (HRV)/<i>Enterovirus</i>, while other pathogens were excluded. The clinical tempo, virologic confirmation, and imaging pattern favored viral acute respiratory distress syndrome (ARDS); drug-related pneumonitis and RA-associated interstitial lung disease remained key differentials. Management included temporary withdrawal of disease-modifying therapy, high-flow nasal oxygen with prolonged awake proning, intermittent non-invasive ventilation during episodes of worsening dyspnoea, a conservative fluid strategy, early de-escalation of empiric antibiotics when cultures remained negative, and a short course of systemic corticosteroids. The patient improved without intubation, was weaned from oxygen, and was discharged in stable condition. MTX was reintroduced without pulmonary relapse; leflunomide was added for residual articular activity. After shared decision-making and due to the patient's aversion to injectables, tofacitinib was restarted, resulting in continued respiratory stability and radiographic resolution on follow-up. This case underscores practical diagnostic discriminators and a stepwise approach to temporarily withholding and safely reintroducing immunosuppression in HRV-ARDS complicating RA treatment.