Successful treatment of Reiter's syndrome in a patient with AIDS with methotrexate and corticosteroids.

Successful Treatment of Reiter's Syndrome in a Patient with AIDS with Metbotrexate and Corticosteroids SIR—Reiter's syndrome (RS) is the most frequent rheumatological disease that occurs in HFV-infected patients. The symptoms may be severe and unresponsive to conventional treatment [1]. Since methotrexate (MTX) is a fairly effective treatment of RS in non-HIV patients, it has been tested in some HIV-positive patients, but it aggravated the underlying immunodeficiency-related diseases. It is therefore generally agreed that this drug should be avoided in such cases. Nevertherless, some patients are so very ill that there is no alternative. We report here the case of a patient with full-blown AIDS and very severe RS who was successfully treated with MTX and corticosteroids, taking stringent precautions. The patient was a 37-yr-old homosexual man. Skin lesions of Kaposi's sarcoma (KS) led to the discovery of HIV seropositivity in 1989. In 1993, the patient had inflammatory polyarthralgias together with cutaneous lesions suggestive of keratoderma blenorrhagica. He was HLA B27 positive. RS was diagnosed and he was successively treated with salazopyrine, bromocriptine and phenylbutazone. Despite these treatments, the clinical status of the patient worsened. He was referred to our department in September 1994 with a severe inflammatory and exudative polyarthritis. The pain was excruciating, requiring morphine sulphate, and the patient was severely incapacitated. There were three cutaneous lesions of KS, diameter 0.5 cm, on the forearm and the thigh. The CD4 count was 19 cells/mm. The patient was treated with 10 mg methotrexate once a week and 10 mg prednisone/day. He was also given malocide and disulone as prophylaxis against Pneumocystis carinii and toxoplasmosis, zidovudine -Ilamivudine and bleomycin (15 mg once a week) for the KS. The result was fair, and remained so for 2 months, but a severe flare-up of polyarthritis in December 1994 required two bolus injections of 250 mg methylprednisolone together with intra-articular infiltrations of corticosteroids. Oral corticotherapy was increased to 20 mg prednisone/day and MTX to 20 mg/week: the arthritis completely subsided and the skin lesions were totally cleared. The patient has now been treated for 8 months and remains free of articular symptoms. Prednisone has been tapered to lOmg/day; the dose of MTX was recently reduced to 10 mg/week. The AIDS treatment has not been altered. The KS was first treated with bleomycin, then with vinblastine and radiotherapy: the lesions remained unchanged. The last CD4 count was 15 cells/mm. Since the first report of RS in HIV-positive patients by Winchester et al., in 1987 [2], MTX has been considered to have adverse effects on the immunodepressive disease, favouring the development of KS sarcoma or P. carinii infection [3, 4]. On the other hand, Maurer et al. [5] recently reported the treatment of three patients with AIDS and severe exacerbations of psoriatic arthritis with high doses of MTX for several months, with a good result on the skin and joint symptoms, and no opportunistic infections in two of them. The patient described here was in severe immunodepression, but he was in dire misery because of his musculoskeletal symptoms, which were insensitive to the usual treatments. His distress prompted us to attempt this controversial therapy, combined with antiviral therapy, chemoprophylaxis of infection and very aggressive therapy against KS. This therapeutic approach was successful, without any exacerbations of the immunodepression-related symptoms. This sort of treatment should be reserved for the most severe cases of RS or psoriatic arthritis, when everything else has failed, but MTX, with or without corticosteroids, should not be systematically rejected for treating RS in patients with AIDS.