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Fever and Cough in Methotrexate-treated Patients: An Approach

L S Aboussouan1, J M Cash

  • 1Departments of Pulmonary and Critical Care Medicine (L.S.A.) and Rheumatic and Immunologic Diseases (J.M.C.), Cleveland Clinic Foundation, Cleveland, Ohio.

Journal of Clinical Rheumatology : Practical Reports on Rheumatic & Musculoskeletal Diseases
|December 17, 2008
PubMed

Insights

Acute methotrexate pneumonitis, a lung condition affecting up to 5.5% of patients, presents with cough, fever, and infiltrates. Diagnosis requires excluding infection and confirming with histology, often responding to corticosteroids.

Area of Science:

  • Pulmonology
  • Rheumatology
  • Pharmacology

Background:

  • Acute methotrexate pneumonitis (AMP) affects up to 5.5% of patients treated with methotrexate.
  • AMP symptoms like cough, dyspnea, and fever can mimic opportunistic infections or underlying rheumatic disease infiltrates.
  • Accurate diagnosis is crucial for appropriate management and to prevent severe outcomes.

Purpose of the Study:

  • To outline the diagnostic criteria for acute methotrexate pneumonitis.
  • To emphasize the importance of differentiating AMP from other pulmonary conditions.
  • To discuss diagnostic methods and treatment strategies for AMP.

Main Methods:

  • Clinical presentation review including cough, dyspnea, fever, pulmonary function tests, and chest radiograph findings.
  • Diagnostic confirmation through exclusion of infection and histologic evidence.
  • Utilizing bronchoalveolar lavage (BAL) for cultures and special stains.
  • Employing transbronchial biopsy and considering open lung biopsy when necessary.

Main Results:

  • Recognition of AMP relies on characteristic clinical symptoms, new pulmonary function abnormalities, and acute radiographic infiltrates.
  • Histologic confirmation and exclusion of infection are essential for definitive diagnosis.
  • BAL and transbronchial biopsies can identify opportunistic pathogens and provide diagnostic material.
  • Open lung biopsy is reserved for cases undiagnosed by bronchoscopy.

Conclusions:

  • Acute methotrexate pneumonitis requires a high index of suspicion and a systematic diagnostic approach.
  • Prompt diagnosis and treatment, including drug discontinuation and corticosteroid therapy, can lead to favorable outcomes.
  • Despite a potential mortality of up to 10%, AMP is often responsive to treatment, highlighting the importance of early recognition.

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