Pott′s disease and hypercalcemia in a patient with rheumatoid arthritis receiving methotrexate monotherapy

Abstract

Methotrexate (MTX) may have adverse effects on multiple organs and system. A few cases of pulmonary tuberculosis in-patients with rheumatoid arthritis (RA) while receiving MTX monotherapy has been reported in the literature. We submit a case of vertebral tuberculosis with hypercalcemia in a patient receiving MTX monotherapy. Patient with RA taking MTX for 15 years developed pancytopenia, skin necrosis, tuberculous spondylodiscitis and hypercalcemia. The present case showed adverse effects of MTX therapy may occur even after years of continuous treatment. Due to pancytopenia in older patients, life-threatening tuberculosis at unusual sites may develop.

Treatment of severe non-infectious uveitis in high-risk conditions (Part 2): systemic infections; management and safety issues

“…Reported experience on the use of IS agents 5.1 Traditional IS agents Current studies regarding this issue are mainly focused on biological therapy, although some studies have indicated the potential risk for developing a TB when using traditional IS agents, particularly MTX. Zorlu et al reported a clinical case of a 74-year-old female patient with RA controlled with MTX monotherapy during 10 years who unusually presented with spondylodiscitis, hypercalcemia, pancytopenia and skin necrosis [145]. In spite of its singularity, this case seems to share certain characteristics with previously reported cases [146] in that, as the authors indicate, there is a need for monitoring these potential complications in patients treated with MTX [145].…”

“…Zorlu et al reported a clinical case of a 74-year-old female patient with RA controlled with MTX monotherapy during 10 years who unusually presented with spondylodiscitis, hypercalcemia, pancytopenia and skin necrosis [145]. In spite of its singularity, this case seems to share certain characteristics with previously reported cases [146] in that, as the authors indicate, there is a need for monitoring these potential complications in patients treated with MTX [145]. Moreover, Chen et al reported the potential relationship between the use of these traditional IS agents for treatment of psoriasis (with or without associated arthritis) and developing of active TB [147].…”

Neuropsychiatric manifestations in rheumatoid arthritis

“…Meningoencephalitis. The treatment of RA patients with immunosuppressive drugs and DMARDS increases the susceptibility of opportunistic central nervous system infections [1,[44][45][46]. Symptoms of CNS infections have a wide range of presentation, such as fever, weight loss, focal neurological deficits, seizures, among others [1].…”

“…Many different agents were described in patients with RA, with especial attention for tuberculosis, neurolues, fungal and viral infections [44][45][46][47][48]. Patients taking TNF-α inhibitors and others biologic agents (such as infliximab, adalimumab, golimumab, etanercept and certolizumab) are at great risk for serious infections events such as tuberculosis and infections caused by opportunistic agents (histoplasmosis, coccidiodomycosis and Pneumocystis pneumonia are the most frequent agents) [49].…”

“…In the settling of negative blood cultures, a biopsy is necessary because some unusual microorganism were described in the context of RA, such as histoplasmosis, Pott's disease, or cryptococcosis [45,46].…”