Low dose methotrexate is used increasingly often in the treatment of rheumatoid arthritis. Severe complications due to toxicity of the lung or bone marrow occur infrequently. This report describes a 71 year old woman with longstanding rheumatoid arthritis who developed pleuritis, a pulmonary infiltrate, and pancytopenia during treatment with low dose methotrexate. Fatal respiratory insufficiency followed, and cultures from the lung after death showed Nocardia asteroides.
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