Effects of Methotrexate Use in a Patient With Rheumatoid Arthritis and Multiple Sclerosis

Abstract

Rheumatoid arthritis (RA) and multiple sclerosis (MS) share similar pathophysiologic processes but coexistence of both diseases in the same patient has rarely been described. We describe the case of a 32 year old woman with rheumatoid arthritis treated with 12.5 mg of methotrexate once a week and 1 mg folic acid who developed paresthesias of her upper and lower extremities. Three years later, she acutely developed 6th nerve palsy, gait imbalance and urinary urgency and a diagnosis of multiple sclerosis was made. The use of methotrexate, though effective in controlling her rheumatoid arthritis, did not influence the development or progression of her multiple sclerosis. Although RA and MS may coexist in the same patient, treatment of one disease may have no influence on the clinical course of the other. Thus, the mechanism by which methotrexate suppresses disease activity in RA but not in MS despite both being T-cell mediated autoimmune diseases requires further investigative studies.

Multifocal inflammatory demyelination in a patient with rheumatoid arthritis and treatment complications

“…Low-dose methotrexate has been found to diminish antigen-stimulated T-cell proliferation [2]. Two placebo-controlled double-blind studies have demonstrated that low-dose oral methotrexate (up to 7.5 mg weekly) may alter the disease course favorably in patients with progressive MS, although the long-term benefits are open to interpretation with some adverse effects [2,6]. Hydroxychloroquine/chloroquine has similar potential immunosuppressive effects including reduction of pro-inflammatory cytokines by macrophages and lymphocytes [7,8].…”

“…Rheumatoid arthritis (RA) and multiple sclerosis (MS) are both autoimmune diseases that share similar pathogenesis particularly of Tcell mediated process [1,2]. Nevertheless, population-based case-control studies have found that prior to the diagnosis of MS, the cases are not more likely than controls to have RA [3].…”

“…Nevertheless, population-based case-control studies have found that prior to the diagnosis of MS, the cases are not more likely than controls to have RA [3]. Although there are increasing reports that MS develops in patients with RA following anti-tumor necrosis factor-alpha (anti-TNF-alpha) treatment [4], the comorbidity of RA and MS in patients with no anti-TNF-alpha treatment has been rarely reported [2,5]. The development of MS after the onset RA is further rare, in the context of the patients being treated commonly with medications such as methotrexate and/or hydroxychloroquine that have potential immunosuppressive effects [2,[6][7][8].…”

“…Although there are increasing reports that MS develops in patients with RA following anti-tumor necrosis factor-alpha (anti-TNF-alpha) treatment [4], the comorbidity of RA and MS in patients with no anti-TNF-alpha treatment has been rarely reported [2,5]. The development of MS after the onset RA is further rare, in the context of the patients being treated commonly with medications such as methotrexate and/or hydroxychloroquine that have potential immunosuppressive effects [2,[6][7][8]. As MS can be clinically silent [9] and autopsy examination of the central nervous system in RA patients is scanty, the association of MS with RA is possibly under-recognized.…”