Minagawa Shunsuke, Takayanagi Noboru, Hara Kenichiro, Takaku Youtaro, Tsutiya Yutaka, Hijikata Naoya, Yamaji Tomohisa, Tokunaga Daidou, Saito Hiroo, Ubukata Mikio, Kurashima Kazuyoshi, Yanagisawa Tsutomu, Sugita Yutaka, Kawabata Yosinori
Department of Respiratory Medicine, Saitama Cardiovascular and Respiratory Center.
Nihon Kokyuki Gakkai Zasshi. 2008 Mar;46(3):237-42.
A 62-year-old woman with rheumatoid arthritis was given 4 mg/body methotrexate (MTX) every week and 5 mg prednisolone every day. She developed a severe cough starting in the evening after starting taking MTX and after a fever of 38 degrees and dyspnea appeared the patient was hospitalized. On admission, chest CT findings showed diffuse ground glass attenuation. Pathological findings of specimens obtained by transbronchial lung biopsy showed alveolitis with epithelioid cell granuloma. As a section of the specimen did not show cyst staining by Grocott stain, MTX-induced pneumonitis was diagnosed. The same day, methylprednisolone pulse therapy was started and trimethoprim-sulfamethoxazole (TMP-SMX) was given simultaneously, while MTX was discontinued. On hospital day 3, subsequent data showed a high serum level of beta-D glucan and a positive PCR result for Pneumocystis jiroveci in bronchoalveolar lavage fluid (BALF). Additional section of the specimen showed eosinophilic foamy areas on HE staining and cysts measuring 8 microm, consistent with the Pneumocystis jiroveci lesions by Grocott stain. We present a case of rheumatoid arthritis complicated by methotrexate-induced pneumonitis in which pneumocystis pneumonia was demonstrated by clinical and pathological findings.
一名62岁的类风湿关节炎女性患者，每周接受4mg/体的甲氨蝶呤（MTX）治疗，每天服用5mg泼尼松龙。在开始服用MTX后的晚上，她出现了严重咳嗽，在体温达到38度且出现呼吸困难后，患者住院治疗。入院时，胸部CT检查结果显示弥漫性磨玻璃样影。经支气管肺活检获取的标本病理检查结果显示为肺泡炎伴上皮样细胞肉芽肿。由于标本的一部分在Grocott染色下未显示囊肿染色，因此诊断为MTX诱导的肺炎。当天开始进行甲泼尼龙冲击治疗，并同时给予复方磺胺甲恶唑（TMP-SMX），同时停用MTX。在住院第3天，后续数据显示血清β-D葡聚糖水平升高，支气管肺泡灌洗液（BALF）中耶氏肺孢子菌的PCR结果呈阳性。标本的额外切片在苏木精-伊红（HE）染色下显示嗜酸性泡沫区域，囊肿大小为8微米，经Grocott染色与耶氏肺孢子菌病变一致。我们报告了一例类风湿关节炎合并MTX诱导的肺炎病例，该病例通过临床和病理检查结果证实了肺孢子菌肺炎。
