Hydroxychloroquine/leflunomide/methotrexate

Abstract

Hydroxychloroquine/leflunomide/methotrexateOrganising pneumonia and rheumatoid arthritis flare: 2 case reports In a case series, two women aged 65 years and a 60 years were described, of whom the 65-year-old woman developed organising pneumonia during treatment with methotrexate, and the 60-year-old woman developed organising pneumonia due to lung injury during treatment with methotrexate and leflunomide for RA [routes not stated; not all durations of treatments to reactions onsets stated].Case 1: A 65-year-old woman presented to outpatient department with pain in multiple small and large joints for 6 weeks duration associated with positive rheumatoid factor and was diagnosed with RA. Thereafter, she started receiving methotrexate 7.5mg/weekly along with oral prednisolone daily. Subsequently, her RA symptoms resolved after one week. However, three weeks later, she presented with progressive shortness of breath on exertion along with non-productive cough, fever and was admitted. She developed tachypnoea with respiratory rate of 24 breaths/minute and oxygenation saturation of 88%. Respiratory examination revealed bilateral lower zone fine crackles. Various laboratory investigations were performed. Chest radiograph revealed bilateral peripheral lower zone infiltrates. A high-resolution CT (HRCT) scan of the thorax revealed bilateral symmetrical patchy consolidation with subpleural regions of bilateral lower lobes. Arterial blood analysis revealed type 1 respiratory failure with ratio of PaO2 /FiO2 ratio 291 requiring nasal prong 3 L/min. Methotrexate was discontinued, and she received antibiotic treatment with ceftriaxone. Bronchoalveolar lavage (BAL) fluid analysis, acid-fast bacilli (AFB) direct smear and Xpert Mycobacterium tuberculosis/rifampicin assay, were negative for bacterial growth, while cytology sample showed no malignant cells. Thus, infection was ruled out and she was diagnosed with organising pneumonia secondary to methotrexate therapy. She was treated with off label IV hydrocortisone 100mg thrice daily, which resulted in significant improvement of respiratory failure within 3 days. Thereafter, she was discharged on off label oral prednisolone 0.5mg/kg/day with slow tapering over a period of 6 months. Methotrexate was discontinued permanently and switched to baricitinib with hydroxychloroquine. One month later, spirometry improved and 4 months later spirometry showed further improvement. She was well and asymptomatic, and repeat chest radiograph showed resolving bilateral infiltrates with residual consolidation at the periphery of left lower zone. Six months after prednisolone initiation, she continued to improve. HRCT scan of the thorax revealed significant interval improvement with residual minimal fibrosis bilateral lower zones with complete resolution of the consolidations.Case 2: A 60-year-old woman with a long-standing history of RA had been receiving methotrexate 15mg weekly and hydroxychloroquine for 3 years. She presented with right knee pain with evidence of synovitis and was diagnosed with ...