Inaba Megumi, Ushijim Sunao, Hirata Naomi, Saisyoji Tetsushi, Kitaoka Mitsuhiko, Yoshinaga Takeshi
Department of Respiratory Medicine, Kumamoto Chuo Hospital.
Nihon Kokyuki Gakkai Zasshi. 2011 Aug;49(8):597-601.
A 76-year-old man who was taking prednisolone and methotrexate for rheumatoid arthritis presented with gastric ulcers. Chest X-ray images showed multiple pulmonary nodules. Transbronchial lung biopsy specimens showed lymphocytic infiltrates but no malignant cells. The radiographic findings gradually ameliorated over a month, but then deteriorated 5 months later. We performed video-assisted thoracoscopic biopsy of the left lung, and the biopsy specimens showed lymphocytic infiltration with necrosis, in which the atypical lymphocytes were positive for Epstein-Barr virus-encoded small RNAs in situ hybridization (EBER-ISH). A diagnosis of lymphomatoid granulomatosis was determined. One year before this diagnosis, the patient was found to have an inflammatory liver tumor that had disappeared spontaneously within a month. A new pathological review of the liver and stomach lesions demonstrated EBER-ISH-positive lymphocytes, and therefore we assumed that they were pathological features of lymphomatoid granulomatosis. The chest radiographic findings improved gradually after the discontinuation of methotrexate. We therefore suggest that methotrexate treatment may be associated with the development of lymphomatoid granulomatosis in patients with rheumatoid arthritis. Lymphoproliferative disorders, including lymphomatoid granulomatosis, should be considered in patients with rheumatoid arthritis who are receiving methotrexate.
一名76岁男性因类风湿关节炎正在服用泼尼松龙和甲氨蝶呤，出现了胃溃疡。胸部X线图像显示多个肺结节。经支气管肺活检标本显示淋巴细胞浸润，但未见恶性细胞。影像学表现一个月内逐渐改善，但5个月后又恶化。我们对左肺进行了电视辅助胸腔镜活检，活检标本显示淋巴细胞浸润伴坏死，其中非典型淋巴细胞在原位杂交中对爱泼斯坦-巴尔病毒编码的小RNA呈阳性（EBER-ISH）。确诊为淋巴瘤样肉芽肿病。在此次诊断前一年，该患者被发现患有炎性肝肿瘤，一个月内自行消失。对肝脏和胃部病变进行的新病理检查显示EBER-ISH阳性淋巴细胞，因此我们认为它们是淋巴瘤样肉芽肿病的病理特征。停用甲氨蝶呤后，胸部影像学表现逐渐改善。因此，我们认为甲氨蝶呤治疗可能与类风湿关节炎患者发生淋巴瘤样肉芽肿病有关。接受甲氨蝶呤治疗的类风湿关节炎患者应考虑包括淋巴瘤样肉芽肿病在内的淋巴增殖性疾病。
