Polyarticular juvenile idiopathic arthritis treated with methotrexate complicated by the development of non-Hodgkin's lymphoma. (Case Report)

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Date: Jan. 2002
From: Archives of Disease in Childhood(Vol. 86, Issue 1)
Publisher: BMJ Publishing Group Ltd.
Document Type: Article
Length: 1,598 words

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A 10 year old boy with juvenile idiopathic arthritis is described. He was treated with methotrexate (MTX) for 2 years 8 months, and presented at routine review with hepatosplenomegaly and suspicious bilateral cervical lymphadenopathy, two months after discontinuing therapy. Magnetic resonance scan revealed significant lymphadenopathy around the upper abdominal aorta and coeliac axis. Lymph node biopsy was consistent with non-Hodgkin's lymphoma, similar to that reported in several adults with rheumatic diseases taking low dose MTX therapy. He was successfully treated with a standard cytotoxic chemotherapy regime, but unfortunately his polyarthritis has subsequently flared some months after completion of his treatment.

CASE REPORT

Clinical findings

A 10 year old boy with a four year history of juvenile idiopathic arthritis (JIA) presented at routine review with bilateral non-tender but firm and suspicious cervical lymphadenopathy. He had hepatosplenomegaly. He had been treated with methotrexate (MTX) 7.5 mg per week, for 2 years 8 months; cumulative dose was 1042.5 mg. The MTX had been given by subcutaneous injection for four months prior to its discontinuation because of nausea associated with oral preparations. MTX had been discontinued two months prior to his presentation with lymphadenopathy as his arthritis had been quiescent for one year. He had also intermittently been treated with daily or alternate daily prednisolone throughout the period of his JIA, and with several intra-articular corticosteroid injections. There were no other co-morbid conditions.

He was admitted for urgent investigation. Full blood count, urea and electrolytes, and lactate dehydrogenase were normal. Serology indicated recent Epstein-Barr virus (EBV) infection, with IgG to EBV detected. Cytomegalovirus (CMV) IgG was not detected. Bone marrow aspirate and trephine revealed no evidence of malignant disease, and there were no malignant cells in his cerebrospinal fluid. Abdominal ultrasound confirmed hepatosplenomegaly and the presence of para-aortic nodes. Magnetic resonance scan revealed a diffusely enlarged spleen, 14 cm in length, with normal texture of liver, pancreas, and both kidneys. There was significant lymphadenopathy around the upper abdominal aorta and coeliac axis, with individual nodes measuring 2 cm in diameter. Computed tomography of the chest revealed evidence of bilateral cervical lymphadenopathy, extending to the sternoclavicular joints. There was no evidence of significant mediastinal or axillary lymphadenopathy, and no evidence of parenchymal lung disease.

Pathological findings

A tissue diagnosis of non-Hodgkin's lymphoma was obtained. Histopathology of a lymph node biopsy revealed T cell rich B cell lymphoma. Most of the larger cells were positive...

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Gale Document Number: GALE|A83028181