Methotrexate/prednisone

Abstract

S Methotrexate/prednisone Pulmonary tuberculosis and cutaneous metastatic tuberculous abscess: case reportA 33-year-old man developed pulmonary tuberculosis, then cutaneous metastatic tuberculous abscess after receiving methotrexate and prednisone.The man had been diagnosed with polymyositis 18 months earlier. He had irregularly received methotrexate 15 mg/week and prednisone 40 mg/day [routes not stated]. He had failed to attend regular follow-up visits, and he had been hospitalised with pulmonary tuberculosis 1 year earlier.The man had been prescribed rifampicin, isoniazid and pyrazinamide. Six months later, he was admitted to hospital with painful warm nodules on his body, along with gummatous lesions that had developed 2 months earlier. He presented with intermittent fever that responded to dipyrone. He also had tachypnoea and tachycardia. Laboratory tests revealed leucocytosis, thrombocytosis and normocytic normochromic anaemia, which persisted during his hospitalisation. He also had increased lactate dehydrogenase and creatine phosphokinase levels; creatine phosphokinase returned to normal levels. Staphylococcal infection was initially suspected; however, his condition did not improve with antibacterial treatment. His fever and rash persisted. Ultrasound confirmed subcutaneous structural alteration on his right leg. Histopathology found oedema of the reticular dermis, acanthosis and mild infiltrate of lymphocytes. There was suggestion of panniculitis, and initial aspirated secretion from lesions was negative for acid-fast bacilli. One week later, a sample showed acid-fast bacilli. He started receiving rifampicin, isoniazid, pyrazinamide and ethambutol. He improved considerably within 5 days. His fever resolved and he was discharged. Culture studies found growth of Mycobacterium tuberculosis. Six months later, his lesions were totally cured.Author comment: "In the present case, the treatment of polymyositis may have induced the development of pulmonary tuberculosis; and one year later the onset of cutaneous disease was observed." da Silva GAR, et al. Cutaneous tuberculous gummas in a patient with polymyositis. Anais Brasileiros de Dermatologia 88: 98