A case of rheumatoid arthritis associated with bisphosphonate-related osteonecrosis of the jaw and methotrexate-associated lymphoproliferative disorde

Abstract

We report a case of rheumatoid arthritis associated with bisphosphonate-related osteonecrosis of the jaw （BRONJ） and methotrexate-associated lymphoproliferative disorder （MTX-LPD）. A 60-year-old woman had spontaneous pain, swelling, and dehiscence of the right mandibular gingiva after the placement of dental implants. The patient was given MTX, steroids, and bisphosphonates to treat rheumatoid arthritis. BRONJ was diagnosed, and anti-inflammatory therapy was administered. On the day of admission, she had a high fever, pancytopenia, liver dysfunction, and hemostatic disorder. MTX-LPD was diagnosed on the basis of the results of a bone marrow biopsy and symptoms. MTX was withdrawn, and chemotherapy was begun. Three months after the start of chemotherapy, FDG-PET scanning showed uptake of FDG in the liver. The patient died 10 months after initial treatment despite intensive care, including several aggressive courses of chemotherapy.