Methotrexate
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Necrobiotic lung nodules: case report. A 74-year-old man developed necrobiotic lung nodules during treatment with methotrexate for rheumatoid arthritis. The man was suffering from seropositive rheumatoid arthritis since 22 years and was treated with methotrexate [route and dosage not stated]. He presented with a non-productive cough and difficulty in breathing, which was progressing since a month. Examination revealed tubular bronchial breath sounds in the infra-axillary and right infrascapular areas. Synovitis was noted in wrists, metacarpophalangeal joints and shoulders along with deformities (clinical disease activity index [CDAI] 48). He was afebrile with no other constitutional features. Chest X-ray revealed a cavity in the right lower zone. Contrast-enhanced computed tomography (CECT) of the chest demonstrated multiple nodules in bilateral lungs with cavitation in some of them. Bronchoscopy, bronchoalveolar lavage, CECT of the abdomen and pelvis were unremarkable. Blood investigations revealed rheumatoid factor 240 IU/mL, erythrocyte sedimentation rate (ESR) 75mm in first hour, anti-cyclic citrullinated peptide 200 U/ml and CRP 54 mg/L. Several other investigations were unremarkable. A CT guided biopsy was scheduled but he denied. Therefore, he was diagnosed with necrobiotic lung nodules of rheumatoid arthritis in view of the bilateral cavitating lung nodules, without malignancy or infection. The man was treated with prednisolone, hydroxychloroquine and leflunomide. Therapy with methotrexate was withdrawn. After three months of initiating the treatment, the synovitis and respiratory symptoms remarkably improved with CDAI score 3. His CRP and ESR became normal, while CT revealed disappearance of the lung nodules. Sharma A, et al. Rheumatoid arthritis with necrotic lung nodules. Journal of the Royal College of Physicians of Edinburgh 50: 307-308, No. 3, Jan 2020. Available from: URL: http://doi.org/10.4997/JRCPE.2020.321 803515340
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Reactions 14 Nov 2020 No. 1830
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