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Nagata Y, Akiba S, Horiuchi H, Okumoto K, Hachinohe S, Ohe R. A case of methotrexate-related lymphoproliferative disease showing multiple liver lesions in a patient with rheumatoid arthritis. Clin J Gastroenterol 2024; 17:705-710. [PMID: 38642276 PMCID: PMC11284183 DOI: 10.1007/s12328-024-01963-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 03/19/2024] [Indexed: 04/22/2024]
Abstract
A 66-year-old woman with rheumatoid arthritis (RA) who had been receiving methotrexate (MTX) for 2 years presented with tarry stools. Contrast-enhanced computed tomography (CT) of the abdomen revealed irregular wall thickening in the ileocecal region and multiple low-contrast masses in both lobes of the liver. Lower gastrointestinal endoscopy revealed a type 2 tumor in the ileocecal region with a semi-peripheral ulcer. Histological examination of liver and colon biopsies showed other iatrogenic immunodeficiency-associated lymphoproliferative disorder (Oi-LPD), diffuse large B-cell lymphoma type, with positivity for Epstein-Barr virus DNA. After withdrawal of MTX, the LPD lesions disappeared and the patient achieved remission. We considered this to be a sporadic case of Oi-LPD, diffuse large B-cell lymphoma type, in the liver and colon due to treatment with MTX. There has been no previous report of this condition with simultaneous hepatic and colonic lesions, and the present case is thought to be highly informative in relation to the pathogenesis.
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Affiliation(s)
- Yamato Nagata
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan.
| | - Shotaro Akiba
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan
| | - Hidekazu Horiuchi
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan
| | - Kazuo Okumoto
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan
| | - Shigemi Hachinohe
- Department of Gastroenterology, Yamagata Prefectural Shinjo Hospital, 720-1 Kanazawa, Shinjo, Yamagata, 996-8585, Japan
| | - Rintaro Ohe
- Department of Pathology, Faculty of Medicine, Yamagata University, Yamagata, Japan
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Miyamoto Y, Kawasoe C, Ito K, Oguri N, Murashima T, Kamibeppu T, Nagai T, Takamori H, Kamimura T, Mukai S, Sato Y, Kamoto T. Hepatic and lung methotrexate-associated polymorphic lymphoproliferative disorders arising during postoperative follow-up of renal cell carcinoma: a case report. J Med Case Rep 2023; 17:524. [PMID: 38129899 PMCID: PMC10740260 DOI: 10.1186/s13256-023-04288-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION Methotrexate induces lymphoproliferative disorders on rare occasions; however, its pathogenesis remains unknown. A clinical diagnosis based on imaging studies alone is often difficult. CASE PRESENTATION A 57-year-old Japanese woman was referred to our department for the evaluation of multiple lung and hepatic nodules that developed during methotrexate treatment for rheumatoid arthritis. Since she had a history of nephrectomy for localized renal cell carcinoma, multiple lung and hepatic metastases were initially considered. However, pathological diagnosis of the lung nodules (needle biopsy) revealed methotrexate-associated polymorphic-type lymphoproliferative disorders. After methotrexate discontinuation, continuous smooth shrinkage of the lung and liver lymphoproliferative disorders was observed. CONCLUSION Methotrexate-associated lymphoproliferative disorders should be considered in the event of newly appearing neoplastic lesions, even during follow-up for renal cell carcinoma, if methotrexate is being administered.
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Affiliation(s)
- Yoshi Miyamoto
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Chihiro Kawasoe
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Kaoru Ito
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Nobuyuki Oguri
- Department of Diagnostic Pathology, Faculty of Medicine, Miyazaki University Hospital, Miyazaki, Japan
| | - Takaya Murashima
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | | | - Takahiro Nagai
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroki Takamori
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Toshio Kamimura
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Shoichiro Mukai
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan.
| | - Yuichiro Sato
- Department of Diagnostic Pathology, Faculty of Medicine, Miyazaki University Hospital, Miyazaki, Japan
| | - Toshiyuki Kamoto
- Department of Urology, Faculty of Medicine, Miyazaki University Hospital, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
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Kitamura T, Shigemura T, Yamamoto Y, Murata Y. Pathological Vertebral Fracture Arising From Methotrexate-Associated Lymphoproliferative Disorder in a Patient With Systemic Lupus Erythematosus. Cureus 2023; 15:e40079. [PMID: 37425534 PMCID: PMC10326866 DOI: 10.7759/cureus.40079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 07/11/2023] Open
Abstract
The incidence of lymphoproliferative disorders associated with methotrexate is rising in patients with rheumatoid arthritis. These disorders typically exhibit spontaneous tumor regression upon discontinuation of methotrexate therapy. Spinal lesions associated with these diseases are extremely rare. We present a case of systemic lupus erythematosus in which the patient developed lumbar spine lymphoproliferative disorders secondary to methotrexate therapy, which failed to regress despite discontinuation of the drug, ultimately leading to pathological fracture necessitating posterior spinal fixation. A 60-year-old woman had been diagnosed with systemic lupus erythematosus at the age of 55 years and had been taking prednisolone, hydroxychloroquine, and methotrexate. Throughout the course of her treatment, she experienced recurrent tumefaction and lymph node swelling in various locations. These masses and lymphadenopathy were believed to be potential complications of methotrexate-associated lymphoproliferative disorders, leading to the discontinuation of methotrexate. One month prior to cessation of methotrexate therapy, the patient presented to an orthopedic clinic with lower back pain, and T2-weighted magnetic resonance imaging revealed low signal intensity in the Th10 and L2 vertebrae, initially misdiagnosed as lumbar spinal stenosis. The patient was eventually referred to our department under suspicion of malignant pathology. Computed tomography identified a vertical fracture of the L2 vertebra, which, in conjunction with the imaging results, led to the diagnosis of pathological fracture secondary to methotrexate-associated lymphoproliferative disorder. Following admission to our department, bone biopsy and percutaneous pedicle screw fixation were performed one week later. Pathological examination confirmed the diagnosis of methotrexate-associated lymphoproliferative disorder. Given the possibility of pathological fracture in patients on methotrexate therapy experiencing severe back pain, additional imaging studies should be considered.
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Affiliation(s)
- Takaki Kitamura
- Orthopaedics, Chiba University, Graduate School of Medicine, Chiba, JPN
| | | | - Yohei Yamamoto
- Orthopaedics, Teikyo University Chiba Medical Center, Ichihara, JPN
| | - Yasuaki Murata
- Orthopaedics, Teikyo University Chiba Medical Center, Ichihara, JPN
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