Publication by Castelino FV, et al (Rheumatology. 2011;50(3):489-493.)

Commentary by Imre Noth, MD, of the University of Chicago Hospitals and Clinics

Article Summary
Castelino FV, Goldberg H, Dellaripa PF. The impact of rheumatological evaluation in the management of patients with interstitial lung disease. Rheumatology. 2011;50(3):489-493.

Introduction: Interstitial lung disease (ILD) represents a heterogeneous group of parenchymal lung disorders with common clinical manifestations. Distinguishing between idiopathic interstitial pneumonitis (IIP) and IP associated with an underlying connective tissue disorder (CTD) can be a daunting task. The authors of this paper hypothesized that a multidisciplinary approach with pulmonologists and rheumatologists working in concert would alter diagnoses and treatment of patients at a tertiary referral center.


  • They reviewed incident IPF or CTD-ILD cases at a multidisciplinary clinic over a 12-month period
  • 50 cases were extensively evaluated by both a pulmonologist and a rheumatologist
  • Baseline characteristics were analyzed
  • The number of changed diagnoses and resultant change in therapies were analyzed


  • 54% of all the cases had a change in the final diagnosis
  • 28% of the IPF cases were reclassified as CTD-ILD
  • 80% of the CTD-ILD patients had a change in therapy, often with the addition of an immunosuppressive agent
  • 27% of the IPF patients had a change in therapy

Expert Opinion:
This work confirms that a comprehensive evaluation of patients with ILD in specialty clinics will alter diagnoses.1 There are several limitations. Several uncontrolled variables make it difficult to attribute the altered diagnoses to a particular practice. Is the change due to the multidisciplinary environment? The academic setting? More experienced pulmonology and rheumatology staff? Better or more diagnostic tests? There is no doubt that the level of resource allocation described in the paper will not be available in many community environments and this type of evidence supports referral of truly difficult-to-distinguish cases to specialty centers. The authors demonstrate an astounding reclassification rate and more importantly change in therapy rate. This small retrospective study underlines the difficulty of accurately diagnosing ILD and argues for tertiary center involvement when possible.


  1. Flaherty KR, Andrei AC, King TE Jr, et al. Idiopathic interstitial pneumonia: do community and academic physicians agree on diagnosis? Am J Respir Crit Care Med. 2007;175(10):1054-1060.