Kougkas Nikolaos, Dara Athanasia, Pagkopoulou Eleni, Dimitriadou Androniki, Papadimitriou Evdokia, Avdelidou Eugenia, Garyfallos Alexandros, Dimitroulas Theodoros
Fourth Department of Internal Medicine, Medical School, Hippokration University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Department of Neurology, Hippokration University Hospital, Thessaloniki, Greece.
Rheumatol Int. 2022 Oct;42(10):1849-1854. doi: 10.1007/s00296-022-05166-5. Epub 2022 Jul 18.
Rheumatoid arthritis (RA) is a systemic inflammatory disease treated with conventional and biologic disease-modifying drugs. Methotrexate is the anchor drug for the treatment of RA and is also frequently used for various autoimmune diseases. Adverse events are common and generally easy to manage, involving mainly the gastrointestinal tract and the liver function. However, neurotoxicity is very uncommon in adults with rheumatic diseases. B cell depletion with rituximab is another therapy approach particularly in patients with refractory RA. Whistle leukoencephalopathy - namely progressive multifocal leukoencephalopathy-is an infrequent but well-described side effect of rituximab. In contrast, central nervous system toxicity due to methotrexate is extremely rare especially in RA individuals under oral or subcutaneous low dose on weekly basis. We present a challenging case of a RA patient on treatment with methotrexate and rituximab presenting with leukoencephalopathy. The patient was diagnosed with methotrexate-induced leukoencephalopathy which reversed after treatment discontinuation. We comment on the symptoms and diagnostic workout and we review the available literature on this issue based on recommendations for narrative reviews.
类风湿关节炎（RA）是一种全身性炎症性疾病，采用传统和生物性病情改善药物进行治疗。甲氨蝶呤是治疗RA的基础药物，也常用于各种自身免疫性疾病。不良事件很常见，且一般易于处理，主要累及胃肠道和肝功能。然而，神经毒性在患有风湿性疾病的成人中非常罕见。使用利妥昔单抗清除B细胞是另一种治疗方法，尤其适用于难治性RA患者。哨笛样白质脑病——即进行性多灶性白质脑病——是利妥昔单抗一种罕见但已被充分描述的副作用。相比之下，甲氨蝶呤引起的中枢神经系统毒性极其罕见，尤其是在每周接受口服或皮下低剂量治疗的RA患者中。我们报告了一例具有挑战性的病例，一名接受甲氨蝶呤和利妥昔单抗治疗的RA患者出现了白质脑病。该患者被诊断为甲氨蝶呤诱导的白质脑病，停药后病情好转。我们对症状和诊断过程进行了评论，并根据叙述性综述的建议，对该问题的现有文献进行了回顾。
