Methotrexate‐associated appearance and rapid progression of rheumatoid nodules in systemic‐onset juvenile rheumatoid arthritis

Abstract

Rheumatoid nodules are a rare extraarticular manifestation of juvenile rheumatoid arthritis (JRA), usually detected in patients with polyarticular‐onset disease and positive rheumatoid factor (RF). To date, there has not been a published report of rheumatoid nodules in systemic‐onset JRA. Low‐dose methotrexate (MTX) is generally considered to be the most useful second‐line drug in the treatment of polyarticular JRA. In adult RA, MTX has been shown to be associated with appearance and progression of rheumatoid nodules. This report describes a 3‐year‐old girl with RF‐negative, antinuclear antibody‐negative systemic JRA who developed multiple rheumatoid nodules on the scalp and trunk during MTX therapy. The first nodule developed on the scalp 6 months after MTX treatment was initiated. Previous treatment with azathioprine was not associated with nodulosis. This represents an atypical case of MTX‐associated accelerated nodulosis in systemic JRA, and raises the problem of treatment plan modification in the presence of this side effect.

Rheumatoid arthritis: A review of the cutaneous manifestations

“…101 One case of MTX-induced accelerated rheumatoid nodulosis in a patient with systemic-onset JRA has been noted, with scalp and trunk nodules 6 months after the start of treatment. 111 Etanercept recently has been implicated in accelerated rheumatoid nodulosis. In 1 case, new nodules appeared over the elbows and metacarpophalangeal joints (as well as pulmonary lesions) after etanercept treatment in a seropositive RA patient with severe articular disease and HLA-DRB1 positivity.…”

Subcutaneous nodules in Henoch-Schönlein purpura

“…Subcutaneous nodules in patients with vasculitis are caused by vasocentric or extravascular cutaneous and subcutaneous inflammation [2] and are reported in a variety of conditions, including rheumatoid arthritis [3][4][5][6][7], rheumatoid nodulosis [3], rheumatic fever [8][9][10][11], hypersensitivity vasculitis [12], systemic lupus erythematosus [13][14][15], polyarteritis nodosa [16][17][18], scleroderma [19], and benign rheumatoid nodule [20][21][22][23][24].…”

The use of methotrexate in childhood rheumatic diseases

“…Accelerated nodulosis has been reported in 3 children treated with MTX for JRA (56,57). Two of these patients had rheumatoid factor (RF)-positive polyarticular JRA, and 1 had systemic-onset JRA.…”