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Intrathecal injection of methotrexate and dexamethasone for vasculitis granuloma of the fourth ventricle: a case report and literature review

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Abstract

Granulomatosis with polyangiitis (GPA) is a pauci-immune small vessel vasculitis characterised by neutrophil-mediated vasculitis and granuloma. The presence of intracranial parenchymal space-occupying lesions is rarely seen in GPA patients. In this manuscript, we report a case of GPA with granuloma of the fourth ventricle accompanied by obstructive hydrocephalus. Treatment with glucocorticoids (GCs) and multiple immunosuppressants cyclophosphamide (CYC), mycophenolate mofetil (MMF), and rituximab (RTX) showed poor efficacy in this case. After removal of the granuloma by craniotomy, GPA relapsed within 3 months. Under the premise of GC and MMF treatment combined with intrathecal injection of dexamethasone (DXM) and methotrexate (MTX), the intracranial granuloma gradually shrank, and the patient’s general condition was alleviated, showing that this is an effective treatment method.

Key Points

• To date, there are few reports of granulomatous vasculitis combined with granuloma of the fourth ventricle, and our case is the second.

• In this case, multiple immunosuppressants and rituximab were ineffective treatments, and the intracranial granuloma was effectively controlled by intrathecal injection of dexamethasone (DXM) and methotrexate (MTX).

• Based on this report, it can be suggested that intrathecal injection is effective in treating patients with GPA and central nervous system involvement, but large-scale sample studies are needed.

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Funding

No specific funding was received from any bodies in the public, commercial or not for profit sectors to carry out the work described in this manuscript.

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Authors and Affiliations

  1. Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, 149 Dalian Road, Huichuan District, Zunyi, 563003, Guizhou Province, China

    Chunyan Li, Yu Wang, Yupei Lin, Qianla Gong, Bangcui Wu, Wendan Zheng, Yingying Tian, Yong Chen & Mei Tian

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  1. Chunyan Li
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  2. Yu Wang
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  3. Yupei Lin
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CL and YW contributed equally to this work and should be considered co-first authors.

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Correspondence to Mei Tian.

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This study followed the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments; written informed consent was obtained; it was explained to the patient; she understood it, and she subsequently signed and was approved by the ethics committee of the institution. Details about the identity of the patient under study were omitted.

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Chunyan Li and Yu Wang contributed equally to this work and listed as first coauthors.

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Li, C., Wang, Y., Lin, Y. et al. Intrathecal injection of methotrexate and dexamethasone for vasculitis granuloma of the fourth ventricle: a case report and literature review. Clin Rheumatol 43, 1217–1226 (2024). https://doi.org/10.1007/s10067-023-06777-4

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  • DOI: https://doi.org/10.1007/s10067-023-06777-4

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