SEVERE PNEUMONITIS AS COMPLICATION OF LOW -DOSAGE METHOTREXATE TREATMENT OF PSORIASIS-ASSOCIATED RHEUMATOID-ARTHRITIS

A 71-year-old woman with psoriasis-associated rheumatoid arthritis had for 15 months been treated with methotrexate (5 mg/week orally). Four weeks before admission she had developed dyspnoea and cough. On admis sion her axillary temperature was 38,2 degrees C, the white cell count was normal. Erythrocyte sedimentation rate (50/90 mm), lactate dehydr ogenase activity (449 U/l) and the creatinine level (1,33 mg/dl) were all elevated. Blood gas analysis revealed partial respiratory impairme nt (pO(2) 52 mmHg), and the chest X-ray demonstrated bilateral interst itial-alveolar changes. Despite antibiotics the temperature continued to rise, and on the 11th day a blood eosinophilia of 4% was noted. The bronchial mucosa was normal on bronchoscopy, and transbronchial biops y showed only minor interstitial fibrosis, occasional macrophages and lymphocytes. Cultures of the lavage-fluid were negative: As methotrexa te pneumonitis was suspected the drug was discontinued and prednisolon e administered (50 mg daily for 3 days, gradually reducing over 7 days ). The symptoms quickly improved, and blood gas analysis and the X-ray s became normal. The patient was discharged symptom-free after 30 days .