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Kato T, Mizumoto C, Inoue F, Watanabe T, Yamanaka S, Fukuhara S, Nakao K. Methotrexate‑related other iatrogenic immunodeficiency‑associated lymphoproliferative disorder in the CNS and medication‑related osteonecrosis of the jaw occurring simultaneously: A case report. Exp Ther Med 2024; 27:41. [PMID: 38125353 PMCID: PMC10731409 DOI: 10.3892/etm.2023.12329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 10/11/2023] [Indexed: 12/23/2023] Open
Abstract
Methotrexate-related other iatrogenic immunodeficiency-associated lymphoproliferative disorder (MTX-OIIA-LPD) is prone to extranodal involvement but rarely involves the central nervous system (CNS). The present study reports a case of MTX-OIIA-LPD of the CNS discovered during medication-related osteonecrosis of the jaw (MRONJ) treatment in a 76-year-old woman with rheumatoid arthritis (RA). The chief complaint of the patient was bone exposure and pain in the right mandibular molar. The patient had been receiving MTX for RA and alendronate sodium hydrate for osteoporosis, followed by denosumab. Treatment was initiated based on a diagnosis of MRONJ. However, the patient experienced lightheadedness and floating dizziness afterwards. Examinations revealed scattered neoplastic lesions in the brain. The histopathological diagnosis was diffuse large B-cell lymphoma. A systemic search also revealed adrenal involvement. Since the patient was taking MTX, a diagnosis of MTX-OIIA-LPD was made and MTX was discontinued. Chemotherapeutic agents were administered since the central lesions became symptomatic. The MTX-OIIA-LPD lesions in the brain and adrenal glands completely resolved 8 months after onset. The physical condition of the patient improved, and the bone-exposed areas became epithelialized. Reports on MTX-LPD in the oral and maxillofacial region are few, which may delay its diagnosis. Therefore, biopsy of oral lesions in patients with MRONJ who are taking MTX and collaboration with related diagnostic departments, such as rheumatology and hematology, must be done to initiate the diagnosis and treatment of extraoral MTX-LPD.
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Affiliation(s)
- Tomoki Kato
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Chisaki Mizumoto
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Fuminori Inoue
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Takuma Watanabe
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shigeki Yamanaka
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Shizuko Fukuhara
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
| | - Kazumasa Nakao
- Department of Oral and Maxillofacial Surgery, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan
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In A, Stopa BM, Cuoco JA, Stump MS, Apfel LS, Rogers CM. Central Nervous System Lymphoproliferative Disorder Secondary to Methotrexate: A Systematic Literature Review and Case Illustration. World Neurosurg 2023; 179:118-126. [PMID: 37574195 DOI: 10.1016/j.wneu.2023.08.018] [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: 04/10/2023] [Revised: 08/02/2023] [Accepted: 08/04/2023] [Indexed: 08/15/2023]
Abstract
BACKGROUND Methotrexate is an immunosuppressant commonly used to treat inflammatory conditions, such as rheumatoid arthritis. However, albeit exceedingly rare, it can have serious adverse effects within the central nervous system (CNS), such as methotrexate-associated lymphoproliferative disorder (MTX-LPD). Literature describing the natural history, treatment options, and clinical outcomes of patients with CNS MTX-LPD remains sparse. METHODS We present a systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and a case illustration of CNS MTX-LPD. RESULTS A systematic review of the literature revealed 12 published cases of CNS MTX-LPD, plus the case presented herein, for a total of 13 included cases. The most common indication for MTX was rheumatoid arthritis. The most common treatment for the LPD was MTX cessation (12, 92.3%), adjunct chemotherapy (2, 15.4%), total tumor resection (3, 23.1%), or steroid therapy (1, 7.7%). Treatment usually led to improvement of neurological symptoms (9, 69.2%) along with regression of the lesions (3, 23.1%) with no recurrence (6, 46.2%). Death was reported in four cases (30.8%) with a mean time from onset of 11 months. CONCLUSIONS CNS MTX-LPD should be considered in the differential diagnosis for patients who are taking MTX presenting with neurologic symptoms, as immediate withdrawal of MTX has demonstrated good prognosis.
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Affiliation(s)
- Alexander In
- Department of Neuroscience, Fralin Biomedical Research Institute, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Brittany M Stopa
- Department of Neuroscience, Fralin Biomedical Research Institute, Roanoke, Virginia, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA.
| | - Joshua A Cuoco
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Michael S Stump
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Department of Pathology, Carilion Clinic, Roanoke, Virginia, USA
| | - Lisa S Apfel
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
| | - Cara M Rogers
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA; Section of Neurosurgery, Carilion Clinic, Roanoke, Virginia, USA; School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, Virginia, USA
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MIZUSHIMA M, ISHI Y, IKEDA H, ECHIZENYA I, OTSUKA T, MITSUHASHI T, YAMAGUCHI S, FUJIMURA M. Successful Treatment of Intracranial Methotrexate-associated Lymphoproliferative Disorder without Epstein-Barr Virus Infection Using Rituximab, Methotrexate, Procarbazine, and Vincristine: A Case Report. NMC Case Rep J 2022; 9:237-242. [PMID: 36061907 PMCID: PMC9398467 DOI: 10.2176/jns-nmc.2022-0091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/08/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Makoto MIZUSHIMA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Yukitomo ISHI
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Hiroshi IKEDA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Ikuma ECHIZENYA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | | | | | - Shigeru YAMAGUCHI
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
| | - Miki FUJIMURA
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine
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Ueno H, Ohno N, Abe T, Kimoto K, Matsuoka C, Giga M, Naito H, Kono T, Takasu M, Kidani N, Yamasaki R, Ichimura K, Nomura E. Prognosis Prediction Using Magnetic Resonance Spectroscopy and Oligoclonal Bands in Central Nervous System Methotrexate-associated Lymphoproliferative Disorder. Intern Med 2022; 61:3733-3738. [PMID: 35598995 PMCID: PMC9841117 DOI: 10.2169/internalmedicine.9296-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Central nervous system methotrexate-associated lymphoproliferative disorder (CNS-MTX-LPD) is rare, but its spontaneous regression has been observed in some patients after withdrawal of agents. We herein report three cases of primary CNS-MTX-LPD that received oral MTX for rheumatoid arthritis. Epstein-Barr virus and oligoclonal bands (OCBs) were positive, while proton magnetic resonance spectroscopy (1H-MRS) showed an elevated lipid peak and slightly elevated choline/N-acetylaspartate ratio in common. After MTX withdrawal, brain lesions showed spontaneous regression in all cases. Our patient's 1H-MRS findings and OCBs may reflect a non-monoclonal lymphoproliferative histology as benign-type lesions in CNS-MTX-LPD.
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Affiliation(s)
- Hiroki Ueno
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Narumi Ohno
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Takafumi Abe
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Kazuki Kimoto
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Chika Matsuoka
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan
| | - Mayumi Giga
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Hiroyuki Naito
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Tomoyuki Kono
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Miyuki Takasu
- Department of Radiology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Naoya Kidani
- Department of Neurosurgery and Neuroendovascular Surgery, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Rie Yamasaki
- Department of Pathology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Koichi Ichimura
- Department of Pathology, Hiroshima City Hiroshima Citizens Hospital, Japan
| | - Eiichi Nomura
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital, Japan
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Hosoi H, Tanaka K, Sakaki A, Kosako H, Iwamoto R, Matsumoto A, Arakawa F, Yamoto T, Murata S, Mushino T, Murata SI, Nakao N, Ohshima K, Sonoki T. Rituximab Monotherapy for Grade 2-3 Lymphomatoid Granulomatosis with Central Nervous System Involvement in a Patient Receiving Methotrexate for Rheumatoid Arthritis. Intern Med 2022. [PMID: 36418093 PMCID: PMC10372291 DOI: 10.2169/internalmedicine.0636-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Lymphomatoid granulomatosis (LYG) is a rare lymphoproliferative disorder (LPD). The optimal management strategy of methotrexate (MTX) related-LPD with central nervous system (CNS) involvement and histological features of LYG remains unclear. We herein report a case of grade 2-3 LYG in a rheumatoid arthritis patient, in which an intracranial mass accompanied by hemorrhaging and pulmonary and skin lesions developed. The patient received successful rituximab monotherapy. The tumor cells in the skin and brain showed monoclonal and oligoclonal proliferation, respectively. Our case suggests that rituximab monotherapy may be effective against MTX-LPD with CNS involvement, especially in cases with LYG histology.
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Affiliation(s)
- Hiroki Hosoi
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Ken Tanaka
- Department of Hematology/Oncology, Wakayama Medical University, Japan
- Department of Pathology, Kurume University School of Medicine, Japan
| | - Ayaka Sakaki
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Hideki Kosako
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Ryuta Iwamoto
- Department of Human Pathology, Wakayama Medical University, Japan
| | - Ai Matsumoto
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Fumiko Arakawa
- Department of Pathology, Kurume University School of Medicine, Japan
| | | | - Shogo Murata
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Toshiki Mushino
- Department of Hematology/Oncology, Wakayama Medical University, Japan
| | - Shin-Ichi Murata
- Department of Human Pathology, Wakayama Medical University, Japan
| | - Naoyuki Nakao
- Department of Neurosurgery, Wakayama Medical University, Japan
| | - Koichi Ohshima
- Department of Pathology, Kurume University School of Medicine, Japan
| | - Takashi Sonoki
- Department of Hematology/Oncology, Wakayama Medical University, Japan
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Ohno M, Kuramitsu S, Iwakoshi A, Yamaguchi J, Ohka F, Saito R. Primary central nervous system malignant lymphoma in a patient with rheumatoid arthritis receiving tocilizumab: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE22256. [PMID: 36088563 PMCID: PMC9706331 DOI: 10.3171/case22256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/16/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Although the risk of developing malignant lymphoma is higher in patients with rheumatoid arthritis (RA) than in the general population, primary central nervous system lymphoma (PCNSL) in patients with RA is extremely rare. In recent years, there has been concern that biological disease-modifying antirheumatic drugs (bDMARDs), widely administered to patients with RA, might increase the risk of cancer development. The authors report the first case of PCNSL in a patient with RA receiving the bDMARD tocilizumab. OBSERVATIONS A 70-year-old man who was diagnosed with RA in 2010 was treated with low-dose methotrexate (MTX) from 2010 to 2015. Tocilizumab was commenced in 2012. In 2018, he developed gait disturbances, and gadolinium-enhanced magnetic resonance imaging showed multiple contrast-enhanced lesions in the basal ganglia and brain stem. Stereotactic brain biopsy led to the diagnosis of diffuse large B-cell lymphoma, and finally PCNSL was diagnosed. He was treated with five courses of MTX 3.5 g/m2, and his disease has been in remission for 34 months. LESSONS Low-dose MTX and bDMARDs are associated with the concern of increased cancer risk in patients with RA. Because tocilizumab has been in use for a relatively short time, further accumulation of cases and careful follow-up are necessary.
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Affiliation(s)
- Masasuke Ohno
- Department of Neurosurgery, Aichi Cancer Center, Nagoya, Japan
| | | | | | - Junya Yamaguchi
- Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan
| | - Fumiharu Ohka
- Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan
| | - Ryuta Saito
- Department of Neurosurgery, Nagoya University School of Medicine, Nagoya, Japan
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Sakairi T, Nakasatomi M, Watanabe M, Hamatani H, Ikeuchi H, Kaneko Y, Handa H, Hiromura K. Primary central nervous system lymphoma in a patient with neuropsychiatric systemic lupus erythematosus receiving mycophenolate mofetil: A case report and literature review. Mod Rheumatol Case Rep 2021; 6:36-40. [PMID: 34505624 DOI: 10.1093/mrcr/rxab012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/30/2021] [Accepted: 07/05/2021] [Indexed: 12/25/2022]
Abstract
A 41-year-old woman with a 14-month history of systemic lupus erythematosus (SLE) presented with headache, aphasia, and agraphia. A laboratory examination revealed mild proteinuria, hypocomplementemia, and elevated anti-double-stranded DNA antibody levels. A cerebrospinal fluid analysis demonstrated elevated protein and interleukin-6 levels. Magnetic resonance imaging (MRI) of the brain identified multiple lesions suggestive of brain edemas and small haemorrhages. She was diagnosed as having neuropsychiatric lupus and lupus nephritis and received remission induction therapy with high-dose corticosteroid and intravenous cyclophosphamide. She achieved a complete remission, and treatment with mycophenolate mofetil (MMF) was initiated 3 months thereafter for remission maintenance. At 13 months after the exacerbation of SLE, she complained of headache and nausea. A gadolinium-enhanced MRI of the brain revealed a low-signal-intensity tumour with marginal ring enhancement of 50 mm in the left frontal lobe. The tumour was excised, and the histological diagnosis was diffuse large B-cell lymphoma with positive Epstein-Barr virus (EBV). MMF was discontinued. Remission induction therapy with rituximab, high-dose methotrexate, procarbazine, and vincristine was administered, and she achieved remission. Previous reports suggest that use of MMF is associated with primary central nervous system (CNS) lymphoma (PCNSL) in patients with lupus nephritis or other autoimmune diseases or in post-transplant patients. Our observation that PCNSL occurred after CNS involvement of SLE suggests that EBV and CNS inflammation arising from SLE might have contributed to the development of PCNSL.
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Affiliation(s)
- Toru Sakairi
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Masao Nakasatomi
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mitsuharu Watanabe
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroko Hamatani
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hidekazu Ikeuchi
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yoriaki Kaneko
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroshi Handa
- Department of Hematology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Keiju Hiromura
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Gunma, Japan
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