Jejunum Perforation Caused by Malignant Lymphoma Following Methotrexate Therapy for Rheumatoid Arthritis

A 62-year-old man was given a diagnosis of chronic rheumatoid arthritis and treated with methotrexate for 5 years. He came to our hospital complaining of acute abdominal pain after having dinner. He presented with abdominal tenderness and muscular defense in the left upper abdomen. CT revealed intra...

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Published inNippon Shokaki Geka Gakkai zasshi Vol. 53; no. 3; pp. 239 - 245
Main Authors Oe, Shoshiro, Yamaoka, Ryoya, Furumoto, Katsuyoshi, Yamaguchi, Masahiko
Format Journal Article
LanguageJapanese
Published The Japanese Society of Gastroenterological Surgery 01.03.2020
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ISSN0386-9768
1348-9372
1348-9372
DOI10.5833/jjgs.2018.0084

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Abstract A 62-year-old man was given a diagnosis of chronic rheumatoid arthritis and treated with methotrexate for 5 years. He came to our hospital complaining of acute abdominal pain after having dinner. He presented with abdominal tenderness and muscular defense in the left upper abdomen. CT revealed intraperitoneal free air, and emergency operation was performed under the diagnosis of acute peritonitis due to gastro-intestinal perforation. During the operation we found an 8-mm perforation in the jejunum, located approximately 120 cm distant from the ligament of Treitz and therefore performed partial resection of the jejunum. The specimen showed an ulcer surrounded with embankment, and histological examination revealed large atypical lymphocytes, positive for CD20, and EBV-encoded small RNA in situ hybridization. We concluded that it was malignant lymphoma, diffuse large B cell type. Lymphoma occurs in some cases in which methotrexate is used for treatment, and it is classified with methotrexate-associated lymphoproliferative disorder. To the best of our knowledge, 7 cases, including this patient with perforation of small intestine caused by methotrexate-associated lymphoproliferative disorder, have been reported in Japan.
AbstractList A 62-year-old man was given a diagnosis of chronic rheumatoid arthritis and treated with methotrexate for 5 years. He came to our hospital complaining of acute abdominal pain after having dinner. He presented with abdominal tenderness and muscular defense in the left upper abdomen. CT revealed intraperitoneal free air, and emergency operation was performed under the diagnosis of acute peritonitis due to gastro-intestinal perforation. During the operation we found an 8-mm perforation in the jejunum, located approximately 120 cm distant from the ligament of Treitz and therefore performed partial resection of the jejunum. The specimen showed an ulcer surrounded with embankment, and histological examination revealed large atypical lymphocytes, positive for CD20, and EBV-encoded small RNA in situ hybridization. We concluded that it was malignant lymphoma, diffuse large B cell type. Lymphoma occurs in some cases in which methotrexate is used for treatment, and it is classified with methotrexate-associated lymphoproliferative disorder. To the best of our knowledge, 7 cases, including this patient with perforation of small intestine caused by methotrexate-associated lymphoproliferative disorder, have been reported in Japan.
Author Yamaguchi, Masahiko
Furumoto, Katsuyoshi
Yamaoka, Ryoya
Oe, Shoshiro
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10) 河野 眞吾,田村 真弘,石山 隼,高橋 玄,五藤 倫敏,坂本 一博.メトトレキサート治療中のリンパ増殖性疾患による回腸穿孔の1例.日本臨床外科学会雑誌.2017;78(11):2469–2473.
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8) 森山 秀樹,大竹 由美子,橋爪 泰夫.慢性関節リウマチに対するメトトレキサート治療中に回腸穿孔を発症した悪性リンパ腫の1例.日本臨床外科学会雑誌.2011;72(6):1461–1464
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11
12
13
1
2
3
4
5
6
7
8
9
10
References_xml – reference: 4) 日本リウマチ学会MTX診療ガイドライン策定小委員会編.関節リウマチ治療におけるメトトレキサート(MTX)診療ガイドライン2016年改訂版.東京:羊土社;2016. p. 45–52, 70–82.
– reference: 12) 吉原 良祐,上藤 淳郎,村田 美紀,中川 夏子,田中 泰史,塩澤 和子.メトトレキサート関連リンパ増殖性疾患27症例の臨床像.臨床リウマチ.2017;29:164–172.
– reference: 7) 古澤 徳彦,池野 龍雄,浦川 雅己,花崎 和弘,宮本 英雄,市川 英幸,ほか.慢性関節リウマチに対するメトトレキセート治療中に発症したEBウイルス関連悪性リンパ腫による回腸穿孔の1例.日本臨床外科学会雑誌.2006;67(11):2625–2629.
– reference: 15) 三谷 祥子,森 茂郎.悪性リンパ腫 診断と治療の進歩 特殊病態と病因 日和見リンパ腫.日本内科学会雑誌.2001;90(6):1038–1043.
– reference: 6) 岩瀬 和裕,山東 勤弥,位藤 俊一,三方 彰喜,水島 恒和,野中 健太郎,ほか.慢性関節リウマチに対するメトトレキサート治療中に悪性リンパ腫による回腸穿孔性腹膜炎を併発した1例.日本外科系連合学会誌.2004;29(4):801–805.
– reference: 8) 森山 秀樹,大竹 由美子,橋爪 泰夫.慢性関節リウマチに対するメトトレキサート治療中に回腸穿孔を発症した悪性リンパ腫の1例.日本臨床外科学会雑誌.2011;72(6):1461–1464.
– reference: 11) 星田 義彦,青笹 克之.悪性リンパ腫のすべて リンパ腫の発病機序 メトトレキサート(MTX).血液・腫瘍科.2004;49:136–140.
– reference: 9) 小野田 正,中川 仁志,戸田 博子,岩谷 佳代子.関節リウマチに対するmethotrexate治療中に発症した悪性リンパ腫による回腸穿孔の1例.外科.2016;78(5):555–559.
– reference: 13) 久下 博之,吉川 周作,増田 勉,内田 秀樹,横谷 倫世,山岡 健太郎,ほか.休薬により自然寛解した直腸肛門部メトトレキサート関連リンパ増殖性疾患の1例.日本大腸肛門病学会雑誌.2017;70(5):310–315.
– reference: 14) Sibilia J, Liote F, Mariette X. Lymphoproliferative disorders in rheumatoid arthritis patients on low-dose methotrexate. Rev Rhum Engl Ed. 1998;65(4):267–273.
– reference: 18) 角 卓郎.メトトレキサート(MTX)関連リンパ増殖性疾患.日本耳鼻咽喉科学会会報.2013;116(6):734–735.
– reference: 1) Ellman MH, Hurwitz H, Thomas C, Kozloff M. Lymphoma developing in a patient with rheumatoid arthritis taking low dose weekly methotrexate. J Rheumatol. 1991;18:1741–1743.
– reference: 2) Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Lyon: IARC Press; 2008.
– reference: 3) 日本リウマチ学会編.関節リウマチ診療ガイドライン2014.東京:メディカルレビュー社;2014.
– reference: 10) 河野 眞吾,田村 真弘,石山 隼,高橋 玄,五藤 倫敏,坂本 一博.メトトレキサート治療中のリンパ増殖性疾患による回腸穿孔の1例.日本臨床外科学会雑誌.2017;78(11):2469–2473.
– reference: 17) Baird RD, van Zyl-Smit RN, Dilke T, Scott SE, Rassam SM. Spontaneous remission of low-grade B-cell non-Hodgkin’s lymphoma following withdrawal of methotrexate in a patient with rheumatoid arthritis: case report and review of the literature. Br J Haematol. 2002;118(2):567–568.
– reference: 5) 早川 正勝,守田 孝司.メトトレキサート治療中に悪性リンパ腫を併発した慢性関節リウマチの1例.リウマチ.1995;35(4):678–682.
– reference: 16) Salloum E, Cooper DL, Howe G, Lacy J, Tallini G, Crouch J, et al. Spontaneous regression of lymphoproliferative disorder in patients treated with methotrexate for rheumatoid arthritis and other rheumatic diseases. J Clin Oncol. 1996;14(6):1943–1949.
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Snippet A 62-year-old man was given a diagnosis of chronic rheumatoid arthritis and treated with methotrexate for 5 years. He came to our hospital complaining of acute...
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SubjectTerms methotrexate-associated lymphoproliferative disorder
perforation
Title Jejunum Perforation Caused by Malignant Lymphoma Following Methotrexate Therapy for Rheumatoid Arthritis
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