Salehi Mashal, Miller Robertha, Khaing Myint
Department of Medicine, NYC Health and Hospitals/Harlem, Columbia University, New York, USA.
Department of Internal Medicine, NYC Health and Hospitals/Harlem, Columbia University, New York, USA.
J Med Case Rep. 2017 Jun 28;11(1):174. doi: 10.1186/s13256-017-1333-0.
Methotrexate has been implicated in a variety of lung complications, one of which is hypersensitivity pneumonitis. Hypersensitivity pneumonitis most often occurs within the first year of starting low-dose orally administered methotrexate. We present a case of methotrexate-induced hypersensitivity pneumonitis after 30 years of methotrexate use, which is the first case to be reported so far.
A 77-year-old African American woman with a history of rheumatoid arthritis presented with progressively worsening shortness of breath and nonproductive cough. She was on a daily dose of 2.5 mg of methotrexate that had been orally administered for the last 30 years. A physical examination was significant for fever of 38.2 °C (100.8 °F), tachycardia, bilateral basal crackles, and oxygen saturation of 88% on room air. A laboratory work up was significant for normal white blood cell count, increased eosinophil count of 18.3%, and erythrocyte sedimentation rate of 111 mm/hour. Sputum cultures were negative for any bacterial pathogens including acid-fast bacilli. Influenza and respiratory syncytial viral infection were ruled out. A (1-3)-B-D-glucan assay (Fungitell®) was within normal limits. Pulmonary embolism was ruled out and echocardiography was normal. A chest X-ray showed hazy opacity with prominent reticulation within the upper lung fields bilaterally, right greater than the left with no pleural effusion. Lung computed tomography revealed nonspecific bilateral upper lung opacification. A pulmonary function test was significant for no obstruction, normal maximum voluntary ventilation, and no restriction, with mildly decreased diffusion. Methotrexate was stopped, and our patient was started on prednisone 60 mg orally administered daily with dramatic clinical and radiologic improvement.
Methotrexate-induced hypersensitivity pneumonitis usually occurs in the initial few weeks to months of starting treatment with methotrexate; however, it can occur late during therapy too, and prompt diagnosis is crucial as it is a reversible condition when diagnosed early.
甲氨蝶呤与多种肺部并发症有关，其中之一是过敏性肺炎。过敏性肺炎最常发生在开始口服低剂量甲氨蝶呤的第一年内。我们报告一例使用甲氨蝶呤30年后发生的甲氨蝶呤诱发的过敏性肺炎，这是迄今为止报道的首例此类病例。
一名77岁患有类风湿关节炎的非裔美国女性，出现进行性加重的气短和干咳。她每日口服2.5毫克甲氨蝶呤，已服用30年。体格检查显示体温38.2℃（100.8°F）、心动过速、双侧肺底部湿啰音，室内空气中氧饱和度为88%。实验室检查显示白细胞计数正常、嗜酸性粒细胞计数增加至18.3%、红细胞沉降率为111毫米/小时。痰培养未发现任何细菌病原体，包括抗酸杆菌。排除流感和呼吸道合胞病毒感染。（1-3）-β-D-葡聚糖检测（Fungitell®）在正常范围内。排除肺栓塞，超声心动图正常。胸部X线显示双侧上肺野模糊不清，有明显网状影，右侧比左侧更明显，无胸腔积液。肺部计算机断层扫描显示双侧上肺非特异性模糊影。肺功能测试显示无阻塞、最大自主通气正常、无限制，弥散轻度降低。停用甲氨蝶呤，患者开始口服泼尼松60毫克/日，临床和影像学表现显著改善。
甲氨蝶呤诱发的过敏性肺炎通常发生在开始使用甲氨蝶呤治疗的最初几周至几个月内；然而，也可能在治疗后期发生，早期诊断至关重要，因为早期诊断时这是一种可逆转的病症。
