Methotrexate induced neurotoxicity in a patient with rheumatoid arthritis on rituximab therapy: a case-based review.

Rheumatoid arthritis (RA) is a systemic inflammatory disease treated with conventional and biologic disease-modifying drugs. Methotrexate is the anchor drug for the treatment of RA and is also frequently used for various autoimmune diseases. Adverse events are common and generally easy to manage, involving mainly the gastrointestinal tract and the liver function. However, neurotoxicity is very uncommon in adults with rheumatic diseases. B cell depletion with rituximab is another therapy approach particularly in patients with refractory RA. Whistle leukoencephalopathy - namely progressive multifocal leukoencephalopathy-is an infrequent but well-described side effect of rituximab. In contrast, central nervous system toxicity due to methotrexate is extremely rare especially in RA individuals under oral or subcutaneous low dose on weekly basis. We present a challenging case of a RA patient on treatment with methotrexate and rituximab presenting with leukoencephalopathy. The patient was diagnosed with methotrexate-induced leukoencephalopathy which reversed after treatment discontinuation. We comment on the symptoms and diagnostic workout and we review the available literature on this issue based on recommendations for narrative reviews.

Fever and temporal headache in a 70-year-old male with presumed large vessels vasculitis.

BACKGROUND: Listeria monocytogenes is an opportunistic pathogen that causes severe infections of the Central Nervous System, such as meningitis or meningoencephalitis, and brain abscesses. Abscesses account for approximately 1-10% of CNS listerial infections and are observed in 1% of all listerial infections. METHODS: We describe a case of 70-year-old male patient who had several admissions in different hospitals over the last 8 weeks. RESULTS: He suffered from intermittent fever for over a month, recurrent episodes of headaches, disorientation and other neurological symptoms. His condition was misdiagnosed as giant cell arteritis and initially the patient was started on corticosteroids. MRI of the brain revealed the presence of multiple brain abscesses and the cerebrospinal fluid study confirmed the presence of Listeria Monocytogenes. The patient was started on ampicillin and he completed a 6 weeks' course of treatment. CONCLUSIONS: This case emphasizes the need to include rare pathogens in the differential diagnosis when possible CNS infections are involved, as well as to show that in many cases some auto-immune diseases are overdiagnosed.

Diagnosis of tuberous sclerosis complex in a patient referred for uncontrolled hypertension and renal dysfunction: a case highlighting the importance of proper diagnostic work-up of hypertensive patients.

: We report a case of a 39-year-old woman with resistant hypertension and renal dysfunction. The patient was hospitalized 3 months earlier for dyspnea at the Department of Cardiology, where she was diagnosed with heart failure (left ventricle injection fraction: 25-30%), pulmonary hypertension, chronic kidney disease (serum creatinine: 1.58 mg/dl), and resistant hypertension and discharged with optimal heart failure treatment. At presentation to our clinic, apart from uncontrolled hypertension for more than 10 years and history of pre-eclampsia and fetal loss, the patient had obesity (BMI: 38 kg/m) and facial fibromas. The first diagnostic steps proposed by the European Society of Hypertension/European Society of Cardiology (ESH/ESC) Guidelines to identify other target-organ damage and causes of secondary hypertension revealed typical proteinuric hypertensive nephropathy, hypertensive retinopathy, and sleep-apnea syndrome. Furthermore, a renal ultrasound showed multiple bilateral renal angiomyolipomas, confirmed by an MRI scan. Following consultation with the Neurology and Dermatology Departments, the diagnosis of tuberous sclerosis complex, based on presence of six major criteria, was confirmed. During the following 10 months, careful adjustments in the patient's antihypertensive treatment, reinforcement of lifestyle interventions, and improved compliance enabled her to reduce her body weight, control blood pressure, improve her heart (left ventricle injection fraction: >40%), and renal injury (creatinine urine clearance: 125 ml/min, urine protein: 178 mg/24 day) and serum triglycerides (153 mg/dl). These improvements enabled the start of everolimus, required for a slight increase in angiomyolipomas' size (3.46 cm) in the repeated examinations.