Methotrexate‐associated appearance and rapid progression of rheumatoid nodules in systemic‐onset juvenile rheumatoid arthritis

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Abstract
Rheumatoid nodules are a rare extraarticular manifestation of juvenile rheumatoid arthritis (JRA), usually detected in patients with polyarticular‐onset disease and positive rheumatoid factor (RF). To date, there has not been a published report of rheumatoid nodules in systemic‐onset JRA. Low‐dose methotrexate (MTX) is generally considered to be the most useful second‐line drug in the treatment of polyarticular JRA. In adult RA, MTX has been shown to be associated with appearance and progression of rheumatoid nodules. This report describes a 3‐year‐old girl with RF‐negative, antinuclear antibody‐negative systemic JRA who developed multiple rheumatoid nodules on the scalp and trunk during MTX therapy. The first nodule developed on the scalp 6 months after MTX treatment was initiated. Previous treatment with azathioprine was not associated with nodulosis. This represents an atypical case of MTX‐associated accelerated nodulosis in systemic JRA, and raises the problem of treatment plan modification in the presence of this side effect.