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Methotrexate, pneumonitis, and infection.

investigations in that direction. Nowadays it is agreed that opportunistic infections, especially Pneumocystis carinii, must be excluded in the evaluation of pneumonitis in patients treated with methotrexate for RA.' In the cases presented this type of pneumonitis could not be fully excluded, especially not in the patient who was also treated with co-trimoxazole. We report the case of a patient who had two episodes of methotrexate related pneumonitis, in which opportunistic infections could be sufficiently excluded. This case history further emphasises that caution is needed when reintroduction of methotrexate after an episode of pneumonitis is considered. A 61 year old man had had erosive, rheumatoid factor positive RA since 1985, previously treated with hydroxychloroquine, sulphasalazine, aurothioglucose, and azathioprine. Chest radiography showed slight reticular changes in the basal segments in August 1987. On pulmonary function testing a restriction (total lung capacity 51 litres (normal 6-1)) and a decreased carbon monoxide diffusing capacity (carbon monoxide transfer factor) (0-93 mmol.min-'.kPa-'.1-' (normal 1-40-1-60)) were found. In November 1987 methotrexate 7-5 mg orally weekly, increasing to 15 mg weekly over two months, was started. Ten months later, at a cumulative methotrexate dose of 540 mg, dyspnoea on effort and a non-productive cough without fever developed, together with mouth ulcers. Chest radiography showed progression of reticular changes, and the carbon monoxide transfer factor had decreased to 0-79. In the absence of sputum production no cultures could be done. Methotrexate was stopped, and low dose prednisone treatment (7-5 mg daily) started. Two weeks later pulmonary complaints and mouth ulcers had disappeared. Control chest radiographs and pulmonary function testing returned to pretreatment values. D-Penicillamine was given for active RA but proved ineffective. In October 1989 methotrexate, 7-5 mg orally weekly, increasing to 10 mg weekly over three months, was restarted, with a sufficient response of the RA. In April 1991 the metho-