BMJ Case Reports 2017; doi:10.1136/bcr-2017-221778
  • Findings that shed new light on the possible pathogenesis of a disease or an adverse effect

Methotrexate-associated lymphoproliferative disease with multiple pulmonary nodules in a patient with rheumatoid arthritis

Open Access
  1. Chang-Youh Tsai1,3
  1. 1Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
  2. 2Division of Allergy, Immunology & Rheumatology, Taipei Veterans General Hospital, Taipei, Taiwan
  3. 3Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
  1. Correspondence to Professor Chang-Youh Tsai, cytsai{at}
  • Accepted 25 October 2017
  • Published 1 December 2017


A 62-year-old woman with rheumatoid arthritis and secondary Sjögren’s syndrome took methotrexate (MTX) 5 mg three times a week regularly but gradually developed an intermittent fever, oral ulcers and productive cough with mucopurulent sputum for about 2 weeks. Image study found multiple nodular lesions and lymphadenopathies in bilateral lungs. Empirical antibiotics for 1 week failed to alleviate the fever. A transbronchial biopsy in the right fourth bronchus showed infiltration of abnormally enlarged lymphoid cells with a surface marker of CD20, some of which also stained positively in situ with Epstein-Barr virus-encoded small RNA and some CD3(+) cells. After a diagnosis of MTX-associated lymphoproliferative disease had been made, MTX was discontinued immediately and intravenous methylprednisolone 125 mg/day was given for 1 week. The clinical condition improved dramatically within 1 month and there was no recurrence after 3-year follow-up.


  • Contributors W-FL wrote the manuscript, Y-PC amended the manuscript, C-WL took care of the patient and collected the pertinent data and C-YT verified all the data as well as supervised the whole study.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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