Formation of multiple pulmonary nodules during treatment with leflunomide / Formação de múltiplos nódulos pulmonares durante tratamento com leflunomida

Pulmonary involvement is one of the extra-articular manifestations of rheumatoid arthritis and can be due to the disease itself or secondary to the medications used in order to treat it. We report the case of a 60-year-old woman who had been diagnosed with rheumatoid arthritis and developed multiple pulmonary nodules during treatment with leflunomide.

O comprometimento pulmonar é uma das manifestações extra-articulares da artrite reumatóide e pode ser devido à própria doença ou secundário às medicações utilizadas para seu tratamento. Este trabalho relata um caso de uma paciente de 60 anos de idade com diagnóstico de artrite reumatoide que evoluiu com múltiplos nódulos pulmonares durante o tratamento com leflunomida.

Azathioprine-induced accelerated cutaneous and pulmonary nodulosis in a patient with rheumatoid arthritis

We report the case of a 42-year-old female with a 5-year history of rheumatoid arthritis treated with Rituximab and Azathioprine. Three months after the initiation of Azathioprine, the patient started with dry cough and noted the rapid development of multiple subcutaneous nodules on her right leg. CT scan of the chest demonstrates pulmonary nodulosis. Skin biopsy was compatible with rheumatoid nodule. A diagnosis of "accelerated cutaneous and pulmonary nodulosis" was considered. Azathioprine was discontinued and Rituximab was restarted. Two months later, most of the subcutaneous nodules had disappeared. This is the second case report of accelerated rheumatoid nodulosis in association with Azathioprine treatment.

Methotrexate induced accelerated nodulosis.

Methotrexate induced accelerated nodulosis (MIAN) is a rare but unique side effect of methotrexate therapy. There is paucity of data from our country about this entity. We analyzed 14 cases of MIAN and studied its association with gender, rheumatoid factor positivity and dose and duration of methotrexate. Fourteen patients (8 females), 12 with rheumatoid arthritis (8 seropositive), one each with juvenile idiopathic (JIA) and psoriatic arthritis (PsA) were detected to have MIAN during study period. All the patients presented with acute onset of multiple nodules. Radial border of fingers was the most commonly involved site. Disease was inactive in all but two patients at the time of appearance of MIAN. There was no association of MIAN with gender, rheumatoid factor positivity, disease duration, cumulative dose and duration of methotrexate therapy. Two patients each were treated with colchicine, D-penicillamine or hydroxy-chloroquine for 3-6 months without any response. We conclude that MIAN is a benign side effect of methotrexate treatment.