Complete Remission of Methotrexate-Related Epstein-Barr-Virus-Associated Hodgkin-Like Lymphoma following Withdrawal of MTX Coupled with Clarithromycin Administration

Abstract

Patients with rheumatoid arthritis (RA) are known to develop lymphoproliferative disorders (LPDs) during the course of illness, particularly in cases treated with methotrexate (MTX) for long periods. We describe a case of MTX-related Epstein-Barr-virus-(EBV-) associated LPD resembling Hodgkin's lymphoma (HL), in which a dramatic complete remission was achieved after withdrawal of MTX coupled with clarithromycin (CAM) administration. Withdrawal of MTX coupled with CAM administration seemed to be effective for treating MTX-related EBV-associated LPDs. In particular, an immunomodulative effect of CAM might have been involved in achieving complete remission.

Figure 1

Imaging test results: the coronal PET image (upper left) shows wide spread pathological uptake of radiotracer (FDG) in cervical, supraclavicular, mediastinal, para-aortic, peri-iliac and inguinal lymph nodes and spleen. A second PET/CT scan performed 2 months after admission (upper right) shows complete resolution of the abnormal FDG activity. Fused PET/CT image on admission (lower left) shows moderate FDG uptake in the spleen.

Figure 2

Histology of the cervical lymph node biopsy showing the infiltration of giant cells reminiscent of Reed-Sternberg cells and atypical large round cells with remarkable nucleoli in the background of lymphocytes, original magnification ×300. H&E stain.

Figure 3

Immunohistochemical stainings for CD20, CD30 and LMP-1 and EBER staining (in situ hybridization). Tumor cells are positive for CD20, CD30, LMP-1 and EBER, original magnification ×300.