Methotrexate
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EBV-associated lymphoproliferative disorder with polyradiculoneuropathy: case report A 56-year-old woman developed polyradiculoneuropathy associated with an Epstein-Barr virus (EBV)-associated lymphoproliferative disorder during treatment with methotrexate for rheumatoid arthritis. The woman’s rheumatoid arthritis had been controlled for 20 years with methotrexate [dosage not stated] and hydroxychloroquine therapy, and for 4 years with prednisone. She presented with a 4-day history of progressive left upperlimb weakness followed by proximal lower-limb weakness and paraesthesia of the hands and abdomen. Examination revealed an asymmetrical weakness, which was predominantly proximal and in the upper limbs. She had diminished reflexes, as well as a decreased perception to touch and pinprick below the umbilicus and above the inguinal region. She had an impaired tandem gait, which progressed to an inability to walk unaided. A proximal conduction block consistent with polyradiculoneuropathy was detected. EMG and nerve conduction studies demonstrated an acute evolving polyradiculoneuropathy with marked recruitment reduction. Symptoms favoured proximal denervation. Her CSF had a protein level of 124 mg/dL and a WBC count of 60/µL with increased lymphocytes; immunophenotyping showed CD20+ B-cells with a monotypic staining pattern for kappa cytoplasmic immunoglobulin light-chains. EBV-DNA was detected in her CSF, while her serum serology was suggestive of a past EBV infection. Bilateral axillary, hilar and mediastinal lymphadenopathy were observed during CT scan. Lymph node biopsy showed CD3+ T-cells and CD20+ B cells with a polyclonal immunoglobulin light-chain staining pattern; numerous EBV-positive cells were also identified. She was diagnosed with polyradiculopathy related to an immunosuppression-induced EBV-associated lymphoproliferative disorder. Methotrexate was discontinued and, 2 weeks after hospitalisation, the woman began receiving rituximab. A CT scan, performed 2 months later, showed reduced lymphadenopathy; at 4 months, she had a gradual nearcomplete neurological recovery. Author comment: "Continued administration of prednisone and hydroxychloroquine did not interfere with recovery making it unlikely that immunosuppression related to these agents caused our patient’s [EBV-associated lymphoproliferative disorder]." Kumar N, et al. Polyradiculopathy due to methotrexate-induced EBV-associated lymphoproliferative disorder. Neurology 71: 1644-1645, No. 20, 11 Nov 2008 801124702 USA
0114-9954/10/1229-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved
Reactions 22 Nov 2008 No. 1229
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