Author Information

An event is serious (based on the ICH definition) when the patient outcome is:

  • * death

  • * life-threatening

  • * hospitalisation

  • * disability

  • * congenital anomaly

  • * other medically important event

A 65-year-old woman developed acute respiratory distress syndrome (ARDS) secondary to acute pneumonitis during treatment with methotrexate [route, dosage and time to reaction onset not stated].

The woman, who had a history of seronegative rheumatoid arthritis (RA), was presented with the complaints of a productive cough and shortness of breath. She was hospitalised recently, for RA flare. She was re-admitted due to healthcare associated pneumonia. On following day, her condition worsened with hypoxaemia and she was found to be in ARDS with marked diffuse bilateral interstitial infiltrates. Subsequently, she was transferred to the ICU for oxygen supplementation. Considering Pneumocystis jiroveci pneumonia (PJP), her antibiotic therapy was broadened.

Eventually, the woman's methotrexate therapy was terminated and high dose corticosteroids were started. Bronchoscopy was negative for PJP, fungi or bacterial organisms. CT scan showed crazy-paving, bronchiectasis and diffuse ground glass opacities. An open lung biopsy with right video-assisted thorascopic surgery showed an inflamed and erythematous lung. Wedge resection biopsies of the right upper, middle, and lower lobes showed cellular and fibrosing interstitial pneumonitis. Additionally, she had temporally heterogeneous subacute on chronic and organizing interstitial pneumonia pattern, reactive type II pneumocyte hyperplasia, eosinophils and non-caseating poorly formed granulomas. Later, she was discharged to a subacute rehab facility with the tapering dose of steroids [outcome not stated].

Author comment: "We discuss a patient who presented to us in acute respiratory distress syndrome (ARDS), later found to be due to low-dose methotrexate-induced acute pneumonitis."