Pediatric Rheumatology Online Journal → June 2003 → Methotrexate→ Abstract #47
METHOTREXATE-INDUCED NODULOSIS IN JUVENILE IDIOPATHIC ARTHRITIS: AN UNCOMMON EVENT WITH SPONTANEOUS RESOLUTION
R. Adwani,1 R. Scuccimarri,1,2 C. M. Duffy.1,2
1Division of Rheumatology, Montreal Children
Background: Nodulosis is a rare manifestation of Juvenile Idiopathic Arthritis (JIA). It most often occurs in polyarticular JIA (Poly JIA) with rheumatoid factor positivity (RF +ve), and may accelerate following the introduction, or after an increase in the dose, of methotrexate (MTx). Objective: To describe 2 patients with Systemic onset JIA (SoJIA), one of whom converted to RF +ve, who developed nodulosis while on treatment with MTx.
Case 1: 15 yo girl with SoJIA, RF -ve, no evidence of rheumatoid nodules at onset. Three months into her disease course while on a combination of indomethacin and prednisone 20 mg/d, her disease flared with evidence of increasing fever, rash and marked polyarthritis. Prednisone was increased to 40 mg/d and MTx, 12.5 mg sq, was added. One month later, she developed 2 distinct rheumatoid nodules, one on the extensor surface of her left elbow and one on the dorsum of her right wrist at the ulnar styloid. RF was now positive. MTx was held at 12.5 mg/wk for several weeks. Due to presistence of disease activity, MTx was increased progressively to 25 mg/wk. Acceleration in nodulosis was not noted and the nodules ultimately resolved. Case 2: 12 yo girl with So JIA, of 4 yrs duration, with no evidence of nodules. Disease was moderately active while on naproxen, prednisone 5mg qod, MTx 20 mg/wk sq, and cyclosporin. Due to increased polyarthritis, MTx was increased to 25 mg/wk. Within 2 weeks she developed a distinct rheumatoid nodule on the extensor surface of her left elbow. RF remained -ve. MTx and other medications were not altered. Over the ensuing 4 weeks the nodule gradually subsided.
Conclusion: Nodulosis may occur after commencement, or after an increase in the dose, of MTx. While it most commonly occurs in Poly JIA, RF+ve, it can occur in patients with SoJIA. In such situations it is not always associated with marked acceleration and it may remit spontaneously despite an increase in MTx dose. The finding of RF+ve in one patient is of interest but remains to be explained.