Background Several pathogens have been previously reported in rheumatoid arthritis (RA) patients treated by corticosteroid pulse therapy (CPT)^1–3 and we recently described a case of upper lobe cavitary tuberculosis in a patient with RA under CPT associated to methotrexate.⁴

Objectives In order to establish the prevalence of tuberculosis infection in RA patients undergoing CPT, we analysed medical charts of consecutive patients affected by these disease who underwent this regimen.

Methods All the records were from patients attending the clinic for at least 2 years since the CPT administration and were analysed in order to detect a clinical diagnosis of tuberculosis. Routine blood analysis and a Chest x-ray film was available for all the patients in the period established for the follow-up, even if asymptomatic. At present, 11 females (mean age 57.54 years, range 40–74) have been identified, who took 1 gr of Methyilprednisolone i.v. daily in a 3-day course of CPT. One of them was taking methotrexate, 3 cyclosporin and 4 the combination of cyclosporin and methotrexate; 3 patients was under no DMARD. CPT was already administered in 3 patients no more than once in the previous year.

Results Two patients revealed a tuberculosis infection, characterised by cavitary lung involvement and meningitis respectively; diagnosis was confirmed by standard methods for tuberculosis in both the patients. One patient affected by tuberculosis belonged to the treatment group CPT + methotrexate, while the other suspended methotrexate less than one year before the administration of CPT.

Conclusion This finding underlines the necessity of close monitoring for severe opportunistic infections in rheumatoid patients during treatment with CPT and MTX, but seem to suggest a more prominent role played by CPT with respect to other DMARDs.

References

1. Weusten BLAM, Jacobs JWG, Bijlsma JWJ. Corticosteroid pulse therapy in active rheumatoid arthritis. Semin Arthritis 1993;23:183–92

2. Van Der Veen MJ, Bijlsma JWJ. The effect of methylprednisolone pulse therapy on methotrexate treatment of rheumatoid arthritis. Clin Rheumatol. 1993;12:500–5

3. Boerbooms AMT, Kerstens PJSM, van Loenhout JWA, Mulder J, van de Putte LBA. Infections during low-dose methotrexate treatment in Rheumatoid arthritis. Semin Arthritis Rheum. 1995;24:411–21

4. di Girolamo C, Pappone N, Melillo E, Rengo C, Giuliano F, Melillo G. Cavitary lung tuberculosis in a rheumatoid arthritis patient treated with low-dose methotrexate and steroid pulse therapy. Br J Rheumatol. 1998;37:1136–7