Cavitary Pulmonary Nodules in Rheumatoid Arthritis: A 17-Year Imaging Follow-Up of Necrobiotic Granulomas

Pulmonary necrobiotic granulomas are a rare extra-articular manifestation of rheumatoid arthritis (RA) that may radiographically mimic infection or malignancy. We present a 57-year-old woman with RA and a smoking history who was found to have subpleural cavitary pulmonary nodules on computed tomography (CT). A biopsy confirmed necrobiotic granulomas. Serial imaging over a 17-year period demonstrated a fluctuating course, including enlargement of lesions from 1.4 cm to 4.4 cm, development of new cavitary nodules, fluid-filled transformation, and partial spontaneous regression. Despite marked radiographic progression, the patient remained clinically stable and was managed conservatively with multidisciplinary follow-up. To our knowledge, such prolonged longitudinal imaging follow-up of rheumatoid pulmonary nodules is rare. This case highlights the prolonged and variable natural history of RA-associated pulmonary nodules and underscores the importance of recognizing their imaging characteristics to prevent unnecessary invasive intervention. Long-term surveillance may be appropriate in asymptomatic patients despite radiologic progression.