Accelerated Nodulosis and Vasculitis Associated with Methotrexate Therapy in a Patient with Rheumatoid Arthritis

 

Patient selection: rheumatoid arthritis or juvenile rheumatoid arthritis being treated with methotrexate

 

Clinical features:

(1) one or both of the following after starting methotrexate therapy

(1a) appearance or enlargement of rheumatoid nodules (accelerated nodulosis)

(1b) appearance or worsening of cutaneous vascularitis

(1c) onset of pericarditis

(2) improvement in these extra-articular findings once methotrexate stopped

 

The patient may experience improvement in articular findings during the methotrexate therapy.

 

The risk for extra-articular manifestations may be associated with certain HLA types such as DRB1*0401.

 

Some patients had reversal of the nodulosis with the addition of hydroxychloroquine while continuing the methotrexate therapy.