Lesson of the month
Stress fracture in long term methotrexate treatment for psoriatic arthritis
M Wijnandsa, A Burgersba Department of
Rheumatology, TweeSteden ziekenhuis, Tilburg, The Netherlands, b Department of Orthopaedic Surgery,
TweeSteden ziekenhuis
Correspondence to: Dr M Wijnands, Department of Rheumatology, TweeSteden ziekenhuis, PO Box 90107, 5000 LA Tilburg, The Netherlands mwijnands@tsz.nl
Accepted for publication 27 February 2001
| The first 150 words of the full text of this article appear below. |
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Case history |
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A 42 year old woman presented at the outpatient rheumatology department with severe, incapacitating pain of her left leg. There was no previous trauma. The patient did not recall fever or malaise.
Psoriasis had been diagnosed at age 17 years. Initially, topical drugs were prescribed. Periodically etretinate, a synthetic analogue of retinoid acid, and photochemotherapy were prescribed as additional treatment. The patient did not receive cyclosporin. Oligoarthritis of her knees and ankles first appeared at an age of 25 years. Management with non-steroidal anti-inflammatory drugs and sporadically an intra-articular injection of corticosteroids was adequate to control the symptoms. At age 37 a severe polyarthritis of elbows, wrists, finger joints, ankles, and metatarsophalangeal joints developed. Treatment with methotrexate (MTX) was started at an initial dose of 7.5 mg weekly, resulting in a good clinical response. Two years later the dosage was gradually increased to 20 mg weekly because of a flare.
On examination there was little pretibial
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