Academic literature on the topic 'Interstitial lung disease, systemic sclerosis, magnetic resonance imaging, computed tomography'

Background:Interstitial lung disease (ILD) is a frequent complication and the major cause of death in Systemic sclerosis (SSc). Computed tomography (CT) is the gold standard imaging technique to assess ILD but is burdened by exposure to ionizing radiations that limits its use for the follow-up. MRI sequences with Ultra Short Echo Time (UTE) are promising for ILD.Objectives:We tested two MRI sequences, UTE Spiral VIBE and Compressing Sensing (CS) VIBE, in SSc-ILD, in comparison to chest CT.Methods:SSc patients with suspected-ascertained ILD were evaluated for undergoing CT-MRI examinations in the same day. Two radiologists visually scored the extent of ground glass opacities (GGO), reticulations, honeycombing and consolidations on CT-MRI. The sum of alteration was assumed as ILD extent. A quantitative texture analysis (qCT) was also performed on CT. Cohen’s k was adopted for interreader concordance in ILD detection. MRI sensitivity and specificity in ILD detection were evaluated. Lin’s concordance was adopted to compare extent analysis between readers and between CT (visual and qCT analysis) and MRI sequences.Results:54 patients performed both CT and MRI. MRI interreader concordance was moderate in ILD detection, while ILD and GGO extent analysis showed good or very good concordance. UTE Spiral VIBE had a sensitivity and specificity in ILD detection of 95.8% and 77.8%, while alterations extent analysis obtained a very good concordance with CT for ILD and GGO. CS VIBE showed a sensitivity and specificity in ILD detection of 46.7% and 95.0%, but a slight or fair concordance with CT in all alterations’ extent analysis.Conclusion:MRI UTE Spiral VIBE sequences are helpful in the evaluation of SSc-ILD. Larger cohorts of patients will be needed to confirm that MRI may be useful in clinical practice, reducing the radiological load of chest CTReferences:[1]Romei C, Turturici L, Tavanti L, et al. The use of chest magnetic resonance imaging in interstitial lung disease: a systematic review. Eur Respir Rev. 2018;27(150):180062. Doi:10.1183/16000617.0062-2018[2]Miller GW, Mugler JP, Sá RC, Altes TA, Prisk GK, Hopkins SR. Advances in functional and structural imaging of the human lung using proton MRI. NMR Biomed. 2014;27(12):1542-1556. doi:10.1002/nbm.3156[3]Pinal-Fernandez I, Pineda-Sanchez V, Pallisa-Nuñez E, et al. Fast 1.5 T chest MRI for the assessment of interstitial lung disease extent secondary to systemic sclerosis. Clin Rheumatol. 2016;35(9):2339-2345. doi:10.1007/s10067-016-3267-0[4]Ohno Y, Koyama H, Yoshikawa T, et al. Pulmonary high-resolution ultrashort TE MR imaging: Comparison with thin-section standard- and low-dose computed tomography for the assessment of pulmonary parenchyma diseases: Pulmonary MRI with UTE in Pulmonary Disease. J Magn Reson Imaging. 2016;43(2):512-532. doi:10.1002/jmri.25008Disclosure of Interests:None declared

BackgroundInterstitial lung disease (ILD) is the major cause of death in Systemic sclerosis (SSc). Computed tomography (CT) is the gold standard imaging technique to diagnose ILD and to assess ILD prognosis. ILD extent assessment at lung CT has shown to correlate with functional lung capacity: extensive lung disease (> 20%) correlate with significant lung capacity decline (forced vital capacity ((FVC) <70%) that is, in fact, associated with a higher mortality. Unfortunately, it is burdened by exposure to ionizing radiations that limits its use for the follow-up. For this reason, new MRI sequences were recently investigated, and Ultra Short Echo Time (UTE) emerged promising for ILD assessment.ObjectivesThe aim of the study is to evaluate the reliability of an MRI-UTE sequence in the assessment of ILD extent in patients with SS in comparison with standard high-resolution CT images and to correlate the extension with pulmonary function tests (PFT).MethodsPatients with SSc and ILD underwent a CT and UTE-MRI (1.5 T) acquisition on the same day. In the same week, they carried out PFT, with FVC and the diffusion capacity of carbon monoxide (DLCo) evaluation. Two thoracic radiologists assessed in consensus, on CT and UTE-MRI, the extent of ILD. Extensions were calculated as the mean percentage of lung involvement, evaluated at five levels, with an approximation of 5%. ILD extension were classified as limited (<20%) or extensive (> 20% or 20% with FVC <70%). The ANOVA test was adopted to compare the CT and MRI extensions of the ILD. Correlations of the extent of CT and UTE-MRI alterations with FVC and DLCo were calculated with Pearson’s correlation coefficient r. Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (VPN) of UTE-MRI were also calculated for UTE-MRI in determining ILD extension.ResultsThe mean ILD extension was 20.9% in CT and 17.9 % in UTE-MRI (p-value=0.64). The correlation of ILD extension in CT with FVC and DLCo were significant (r=-0.66 (p<0.0001) and r=-0.59 (p<0.0008), respectively). The correlation of ILD extension in UTE-MRI with FVC and DLCo were significant (-0.68 (p<0.0001) and -0.57 (p<0.002), respectively) too. The UTE-MRI assessments agreed with CT in identifying limited or extensive ILD in 25/29 patients (19 limited and 6 extended) and discordant in 4 (1 limited and 3 extended to CT). UTE-MRI sensitivity and specificity in identifying extended ILD were high (86.4% (65.1% -97.1%) and 85.7% (42.1% -99.6%), respectively). PPV and NPV were 95.0% (75.4% -99.2%) and 66.7% (40.7% -85.7%), respectively.ConclusionUTE-MRI sequence, compared to CT, has shown high correlation with PFR and comparable ability in identifying patients with extensive ILD. Therefore, UTE-MRI seems new promising imaging sequence for the evaluation of ILD extension in SSc patients.References[1]Orlandi M, Landini N, Cerinic MM, Colagrande S. Pulmonary magnetic resonance imaging in systemic sclerosis: a jump in the future to unravel inflammation in interstitial lung disease. Clin Rheumatol. 2021 Sep;40(9):3461-3464. doi: 10.1007/s10067-021-05869-3. Epub 2021 Jul 30. PMID: 34328571.[2]Romei C, Turturici L, Tavanti L, et al. The use of chest magnetic resonance imaging in interstitial lung disease: a systematic review. Eur Respir Rev. 2018;27(150):180062. Doi:10.1183/16000617.0062-2018[3]Pinal-Fernandez I, Pineda-Sanchez V, Pallisa-Nuñez E, et al. Fast 1.5 T chest MRI for the assessment of interstitial lung disease extent secondary to systemic sclerosis. Clin Rheumatol. 2016;35(9):2339-2345. doi:10.1007/s10067-016-3267-0Disclosure of InterestsNone declared

Background:The prevalence of SLE pulmonary involvement varies depending on several factors, including diagnostic methods [1].Objectives:We aimed to determine the frequency of involvement with different diagnostic methods in a single center cohort.Methods:300 SLE patients were included. Chest x-ray (CXR), lung spirometry, carbonmonoxide diffusion test (DLCOc) and echocardiography were performed. High resolution thorax computed tomography (HRCT) was done for a definite diagnosis of interstitial lung disease (ILD) whilst diagram electromyography (EMG), ultrasonography (USG) and magnetic resonance imaging (MR) were utilized to diagnose shrinking lung syndrome (SLS).Results:The mean age and follow-up time were 43 and 11,5 years respectively. Of 300 patients, 16% had ILD, 6,7% had pulmonary hypertension (PHT), 3% had SLS, 0,3% had pulmonary infarction. At the start of the study, patients’ records showed that 4% had ILD, 5% PHT, 0,3% SLS and 0,3% pulmonary infarction. The median age, mean duration of disease and follow-up time were significantly higher and longer in patients with ILD compared to patients without (p<0.05). Forced expiratory volume (FEV1), forced vital capacity (FVC), DLCOc and total lung capacity (TLC) were significantly lower in patients with ILD and with SLS (p<0,001). Patients with ILD had significantly higher frequency of arthritis, serositis, Raynaud myositis and anti-Scl70 positivity. Avascular necrosis, diabetes and malignancy were significantly more frequent in those patients. All patients with suspected SLS undergone diagram EMG, USG and MR. Out of 10 suspected cases, in 6 EMG, in 5 USG and in 9 MR was compatible with SLS diagnosis. 5 patients had 3 of the diagnostic methods positive to diagnose SLS. Muscle atrophy and weakness, avascular necrosis were more frequent in this group of patients (p<0.05). There were more patients treated with mycophenolate mofetil (MMF) and cyclophosphamide in the SLS group whilst more with MMF in the ILD group. Significantly higher frequency of patients had stopped using hydroxychloroquine (HCQ) in the ILD group (p=0,04).Conclusion:Interstitial lung disease is common in patients with SLE and considerable number of patients have SLS [2]. Spirometry, DLCOc and CXR are simple but valuable to diagnose pulmonary involvement in SLE patients. Diaphragm MR, USG and EMG are complementary methods for definite diagnosis in SLS [2]. Considering the significant difference of prevalence between the start and the end of the study, one of the possibbilities is the underrecognition of SLE pulmonary disease due to its being part of a multisystemic presentation. Higher usage of immunosuppressives in these patients may support a multisystemic active disease. Although drug effect is another concern, it is hard to establish a causal relationship due to the study’s cross-sectional design. HCQ may have a role in ILD prevention.References:[1]Keane MP, Lynch JP. Pleuropulmonary manifestations of systemic lupus erythematosus. Thorax 2000;55:159-166.[2]Singh R, Huang W, Menon Y, Espinoza LR. Shrinking lung syndrome in systemic lupus erythematosus and Sjogren’s syndrome. J Clin Rheumatol. 2002 Dec;8(6):340-5.Table 1.Spirometry; DLCO; diaphragm EMG, USG and MRI results of patients with SLS.Patient/Age/Sex1/44/F2/57/F3/39/F4/38/M5/23/F6/60/F7/58/F8/37/F9/66/F10/28/FFEV1 (%)47655963676271537039FVC (%)56735962797072556237DLCO (%)45504465535547656245TLC (%)61716566786454636245USG deep inspiration (L)4,704,742,593,013,063,065,734,172,121,59USG deep inspiration (R)3,721,982,262,242,772,174,672,834,622,49USG diaphragm thickness (L)4,823,002,482,842,551,592,093,181,621,44USG diaphragm thickness R(R)1,231,041,841,802,191,311,791,972,081,63MR high sideRRRRRRRLLMR height difference4,926,192,872,641,672,451,730,950,78EMG resting AMP (R)0,20,30,60,50,60,40,10,80,90,7EMG resting LAT (R)76,47,166,786,154,7565,8EMG resting AMP (L)0,40,50,80,71,20,60,31,20,50,5EMG resting LAT (L)6,355,756,855,66,05664,355,26,15Disclosure of Interests:None declared

Patients with systemic sclerosis are at high risk of developing systemic sclerosis–associated interstitial lung disease. Symptoms and outcomes of systemic sclerosis–associated interstitial lung disease range from subclinical lung involvement to respiratory failure and death. Early and accurate diagnosis of systemic sclerosis–associated interstitial lung disease is therefore important to enable appropriate intervention. The most sensitive and specific way to diagnose systemic sclerosis–associated interstitial lung disease is by high-resolution computed tomography, and experts recommend that high-resolution computed tomography should be performed in all patients with systemic sclerosis at the time of initial diagnosis. In addition to being an important screening and diagnostic tool, high-resolution computed tomography can be used to evaluate disease extent in systemic sclerosis–associated interstitial lung disease and may be helpful in assessing prognosis in some patients. Currently, there is no consensus with regards to frequency and scanning intervals in patients at risk of interstitial lung disease development and/or progression. However, expert guidance does suggest that frequency of screening using high-resolution computed tomography should be guided by risk of developing interstitial lung disease. Most experienced clinicians would not repeat high-resolution computed tomography more than once a year or every other year for the first few years unless symptoms arose. Several computed tomography techniques have been developed in recent years that are suitable for regular monitoring, including low-radiation protocols, which, together with other technologies, such as lung ultrasound and magnetic resonance imaging, may further assist in the evaluation and monitoring of patients with systemic sclerosis–associated interstitial lung disease. A video abstract to accompany this article is available at: https://www.globalmedcomms.com/respiratory/Khanna/HRCTinSScILD

Abstract Introduction/Background A 45-year-old lady, originally from Peru, with a background of diffuse cutaneous systemic sclerosis presented with shortness of breath on exertion, frequent palpitations, non-exertional chest tightness, and fatigue. Description/Method In 2011, she presented with inflammatory arthritis as well as Raynaud’s phenomenon. Her anti-nuclear antibody screen showed a positive anti-SCL-70 and anti-U3RNP. Over the years she developed pulmonary hypertension, renal involvement (proteinuria), dysphagia, cutaneous involvement (sclerodactyly, digital ulcers, telangiectasia) and interstitial lung disease. She was commenced on methotrexate and prednisolone. Her pulmonary hypertension was controlled on macitentan and sildenafil. Her pulse was 112 beats per minute, regular with a blood pressure of 168/85 mmHg. She had a loud P2 and a parasternal heave. She had sparse basal crepitations. She had mild pitting oedema to her knees. Her JVP was not raised. Her weight was 38kg. Her right heart catheterisation in April 2021 reported a mean pulmonary artery pressure of 24mmHg and pulmonary vascular resistance of 255 ARU. A computerized tomography (CT) scan of her chest showed known interstitial lung disease and no pulmonary embolism. Her lung function tests were stable. A cardiovascular magnetic resonance imaging (CMR) guided cardiac catheter in April 2021 showed scleroderma involvement of the heart, with mild pericardial effusion and elevated native myocardial T1 and T2. Left ventricular ejection fraction was normal. The impression was that of scleroderma with myocardia involvement. Her immunosuppression was escalated to cyclophosphamide. A cardiac MRI in September 2021 showed improvements in T1 and T2 mapping parameters. She completed 4 cycles of cyclophosphamide (15mg/kg). However, due to gastrointestinal side effects (nausea and vomiting) and a diagnosis of latent tuberculosis in February 2022, cyclophosphamide was stopped. In March 2022, her repeat CMR showed that the T1 and T2 mapping had slightly increased and presented again with chest pain and palpitations. Following a multi-disciplinary team discussion, the patient was treated with rituximab 500mg two weeks apart with 100mg of methylprednisolone as premedication prior to the infusions. Discussion/Results Although subclinical cardiac involvement in scleroderma is common, only 10 to 30% of patients are symptomatic. Our patients complained of non-exertional chest pain. Macrovascular coronary disease had been excluded; the cause of her chest pain was likely secondary to microvascular dysfunction. In patients with cardiac scleroderma, the mechanism of coronary disease is secondary to myocardial inflammation and repeated microvascular ischaemia. This results in reperfusion defects secondary to necrosis, in turn driving myocardial fibrosis. In the late stages, fibrosis results in left ventricular diastolic dysfunction, a complication related to increased mortality. Supraventricular tachycardia is one of the manifestations in conduction abnormalities in cardiac scleroderma: others include conduction defects and bradyarrhythmias. As with our patient, tachyarrhythmias can be associated with symptoms such as generalised fatigue, shortness of breath, and exercise intolerance. Another complication found on imaging was a small pericardial effusion. This is the most common pericardial disease in scleroderma. For most, pericardial effusions are asymptomatic; however, it can be associated with complications such as tamponade. Whilst cyclophosphamide is a common treatment choice for scleroderma with cardiac involvement, evidence for this is limited to case series due to its rarity. Additionally, it carries significant toxicity: Our case developed significant nausea and vomiting following her third and fourth cyclophosphamide infusions and this was discontinued also in light of her diagnosis of latent TB. Rituximab, the agent to which the patient was subsequently switched, similarly has a growing body of evidence in cardiac scleroderma. Since her rituximab infusions, our case has remained stable and she has noticed an improvement of her clinical symptoms. Key learning points/Conclusion Cardiac scleroderma is associated with significant reduction in quality of life, morbidity, and mortality. It is often difficult to treat due to sparsity of high-quality evidence (as in other rare conditions) as well as the multiple organ systems and co-morbidities involved. This case illustrates the clinical manifestation of cardiac scleroderma and the difficulty in selecting appropriate immunosuppression medication.

Abstract Background The peculiar presentation of overlap syndrome in children makes precise diagnosis difficult. Children with overlap syndrome may or may not have specific antibodies. We present the case of a 12-year-old girl diagnosed with overlap syndrome of systemic lupus erythematosus (SLE) and juvenile polymyositis (JPM) who tested positive for anti-OJ antibodies. Case presentation We describe the case of a 12-year-old girl diagnosed with SLE at the age of 7 and presented with fever with malar rash, periungual erythema, generalized weakness, and multiple joint pain at admission. The patient had persistent joint pain and weakness after intravenous methylprednisolone administration and complained of an inability to walk with a positive test for Gower's sign one week after admission, accompanied by elevated alanine aminotransferase (ALT) and creatine-phospho-kinase (CPK) levels. The results of nerve conduction velocity test were normal. Electromyography revealed abundant spontaneous activity and myopathic motor unit action potentials in the right deltoid, biceps, and iliopsoas, in addition to fibrillation and mild myopathic motor unit action potentials in the right rectus femoris muscle. Magnetic resonance imaging revealed diffusely increased signal intensities in the myofascial planes of the bilateral iliopsoas, gluteus, obturator, pectineus, and hamstring muscles. Anti-nuclear antibody, anti-RNP, and rheumatoid factor IgG tests were positive, and inflammatory myopathy autoantibodies revealed anti-OJ antibody positivity, which strongly indicated autoimmune myositis. High-resolution computed tomography of the lung revealed mild pericardial effusion without any evidence of interstitial lung disease. We initiated intravenous pulses of methylprednisolone treatment, followed by cyclosporine, mycophenolate mofetil, and oral steroids. Clinical improvement with a delayed, slowly reduced CPK level after the above treatment and she was discharged after the 18th day of hospitalization. Conclusion Overlap syndrome with inflammatory myositis can occur years later in pediatric SLE cases. We should be alert when patients with SLE develop a new presentation characterized by decreased SLE-specific autoantibody titers, positive anti-RNP antibodies, and elevated CPK. Treatment of the overlap syndrome of SLE and JPM is individualized, and the course differs between pediatric and adult patients.

Background: Hypertrophic cardiomyopathy is the most common acquired cardiovascular disease in the feline species. A frequent complication of this cardiomyopathy is the development of cardiac congestive failure, left atrial enlargement and subsequent development of arterial thromboembolism. In a significant percentage of affected animals there is progression to congestive heart failure, resulting in cyanosis and dyspnea, often the first clinical signs reported by owners. This is a report of a 10-year-old Persian cat with hypertrophic cardiomyopathy and venous and arterial thromboembolism of non-cardiogenic origin.Case: The patient was referred for cardiac evaluation, arterial thromboembolism was the suspected cause of tetraparesis. On clinical examination, a metacarpal pulse was present in all limbs; there was no cyanosis or peripheral hypothermia thus, ruling out a thromboembolic event in the limbs. Changes consistent with feline asthma and pulmonary edema were seen on radiographs, therefore hypertrophic cardiomyopathy was suspected. Treatment with enalapril (0.25 mg/kg every 12 h) for the heart condition and prednisolone (1 mg/kg every 24 h) for asthma was started. Nine days later, the patient developed mixed dyspnea (inspiratory and expiratory) and was hospitalized with signs consistent with arterial thromboembolism: paralysis and cold extremities in the right and left pelvic limbs. The patient was euthanized due to the poor prognosis. Post mortem and histopathological findings revealed left ventricular concentric hypertrophy, with no valvular changes; disseminated intravascular coagulation, with thrombi in the arterial (iliac arteries, pancreatic and renal vessels) and venous (pulmonary and renal veins) beds; as well as multiple neoplastic lung masses, identified as scirrhous pulmonary adenocarcinoma, responsible for increased interstitial radiopacity. Metastasis was also identified at the tracheal bifurcation, causing radiographic changes similar to the alveolar pattern of pulmonary edema.Discussion: The origin of the concentric left ventricular hypertrophy was not established. Both primary hypertrophy, due to breed-related genetic predisposition or secondary hypertrophy, due to systemic hypertension from chronic kidney disease are possibilities. However, despite the left ventricular concentric hypertrophy and the presence of thrombus under the mitral valve, it was not thought that the patient had cardiogenic thromboembolism, since this would not explain the venous thrombi. The arterial and venous thromboembolism in this case were the result of paraneoplastic syndrome due to pulmonary adenocarcinoma, which was a triggering factor for disseminated intravascular coagulation and multiple thrombus formation, both in arterial and venous beds. Tumor cells may promote direct and indirect modifications in the coagulation cascade and, thus hypercoagulability. The hypercoagulatory state promoted by the tumor associated with the Virchow triad seen in feline species, explains the occurrence of thrombosis in this case report. Sensitive imaging tests, such as computed tomography or magnetic resonance imaging, may be required in middle-aged cats with hypertrophic cardiomyopathy and clinical presentations of thromboembolism or respiratory signs, in order to exclude pulmonary neoplasm as a differential diagnosis for thrombus formation and dyspnea. Furthermore, it is speculated that the antitumor effect of heparin used in the treatment for arterial thromboembolism may delay the diagnosis of lung neoplasia in cats.

Purpose/Objectives Interstitial Lung Disease (ILD) is a major complication of Systemic Sclerosis (SSc), with high morbidity and mortality. Computed tomography is the gold standard for ILD imaging assessment. However, recent Ultra-Short Echo-Time (UTE) Magnetic Resonance Imaging (MRI) sequences are promising for lung parenchyma evaluation. Moreover, different Dynamic Contrast Enhancement (DCE) MRI patterns seems able to identify prevalent inflammatory and fibrotic ILD, with possible implications in the management of the therapy. We aimed to verify the reliability of respiratory triggered UTE Spiral VIBE-MRI sequence in SSc-ILD assessment, compared to Computed Tomography (CT). Moreover, we tested the feasibility of DCE-MRI ILD analysis. Materials and methods 54 SSc patients performed chest CT and MRI in the same day. The MRI protocol included a UTE Spiral VIBE sequence before contrast administration and a VIBE sequence, scanned pre and post contrast administration (after 1, 3, 5 and 10 minutes). Two radiologists, independently and in consensus, analyzed CT and UTE verifying ILD presence/absence and performing a semiquantitative analysis (sQA) of ILD, Ground Glass Opacities (GGO), Reticulations and Honeycombing (HC) extents on CT and UTE. A CT software quantitative texture analysis (QA) of alterations extents was also performed. Then, in patients with ILD on CT, the two readers assessed the prevalent CE pattern as following: pattern 1) early enhancement and washout with discernible peak enhancement at 1 or 3 min; pattern 2) slight enhancement with no discernible peak enhancement at a specific time-point; and pattern 3) delayed persistent enhancement with discernible peak enhancement at 5 or 10 min. Pattern 1 was considered inflammatory, patterns 2 3 and 3 fibrotic. For ILD detections as well as for DCE MRI analysis, intra- and inter-reader agreements were computed with Cohen’s K coefficient. UTE sensitivity and specificity for ILD detection against CT were assessed. For extents analysis, intra-/inter-reader agreements and UTE performance against CT were computed by Lin’s concordance coefficient (CCC). Results 51 subjects were included for visual assessment, as 3 UTE were discarded for low quality. ILD was diagnosed in 39/51 CT. 16 out of the 51 included patients accepted to underwent VIBE pre and post contrast administration scans: 14 patients had ILD on CT and DCE-MRI were analyzed (no one discarded for low quality). UTE intra and inter-reader K in ILD diagnosis was 0.56 and 0.26, respectively. UTE showed 92.8% sensitivity and 75.0% specificity in ILD detection. 42 out of 51 QA segmentations were accepted. ILD, GGO and Reticulations extents were 14.8%, 7.7% and 7.1% on CT sQA and 13.0%, 11.2% and 1.6% on CT QA. HC was <1% and not further considered. UTE intra- and inter-reader CCC was 0.92 and 0.89 for ILD extent and 0.84 and 0.79 for GGO extent, respectively. UTE RET extent intra and inter-reader CCC was 0.22 and 0.18, respectively. ILD and GGO extents CCC were 0.95 and 0.93 against CT sQA and 0.89 and 0.88 against QA. RET extent CCC were 0.35 against CT sQA and 0.22 and against CT QA. DCE-MRI analysis has intra- and inter- reader K of 1 and 0.63 (disagreement in one patient), respectively. Only one patients demonstrated a prevalent inflammatory pattern. Conclusions In SSc patients, UTE Spiral VIBE-MRI sequence may suffer of low inter-reader agreement in ILD detection, but it is a reliable tool in assessing ILD and GGO extents in ascertained ILD. DCE-MRI ILD evaluation seems feasible could add information on inflammatory ILD activity.