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Intracranial Methotrexate-Associated Lymphoproliferative Disorder in Rheumatoid Arthritis

Shizuka Miyaza1, Ryosuke Matsuda2, Mitsutoshi Nakamura2

  • 1Department of Neurosurgery, Higashiosaka City Medical Center, Higashiosaka, Japan.

World Neurosurgery
|July 12, 2019
PubMed
Abstract

Insights

Long-term methotrexate treatment for rheumatoid arthritis can rarely lead to intracranial lymphoproliferative disorders (LPDs). Prompt discontinuation of methotrexate and steroid therapy resolved symptoms in a patient with this rare condition.

Area of Science:

  • Neurology
  • Rheumatology
  • Oncology

Background:

  • Methotrexate (MTX) is a primary treatment for rheumatoid arthritis (RA), managing pain and inflammation.
  • Long-term MTX use is associated with an increased risk of lymphoproliferative disorders (LPDs).

Observation:

  • A 68-year-old woman with a 15-year history of RA and 5 years of MTX therapy presented with progressive right limb palsy.
  • Brain MRI revealed a ring-enhancing lesion in the left parietal lobe, confirmed by biopsy as CD20-positive atypical lymphocytes with Epstein-Barr virus (EBV) RNA.
  • The patient was diagnosed with an intracranial MTX-associated LPD.

Findings:

  • Discontinuation of MTX and initiation of steroid therapy led to significant reduction in the intracranial lesion size.
  • The patient's neurological symptoms resolved completely after MTX withdrawal.
  • No recurrence of the LPD was observed at a 3-year follow-up.

Implications:

  • Intracranial MTX-associated LPD is an exceptionally rare but serious complication of RA treatment.
  • Increased vigilance for LPD is crucial in RA patients undergoing immunosuppressive therapy.
  • This case highlights the importance of considering iatrogenic causes for neurological deficits in RA patients on long-term MTX.
Keywords:
Lymphoproliferative disorderMethotrexateRheumatoid arthritis

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