Patient with rheumatoid arthritis on methotrexate with multiple infecting organisms causing gastritis

BMJ Case Rep. 2013 Jul 31;2013:bcr2013009194. doi: 10.1136/bcr-2013-009194.


A 70-year-old man with a medical history of rheumatoid arthritis on methotrexate 2.5 mg every other day was being followed for cytomegalovirus (CMV) gastritis and Helicobacter pylori infection, who was also found to have adrenal masses bilaterally. A CT showed a 1 cm left adrenal nodule along with a 2.5 cm right adrenal mass suspicious for malignancy. A positron emission tomography showed metabolic activity in his adrenals that was non-specific (could be seen in benign as well as malignant lesions). The patient was started on valganciclovir 900 mg daily for 30 days. Following treatment the patient showed marked clinical improvement with a weight gain of 9 lbs and a complete resolution of his epigastric pain. A repeat oesophagogastroduodenoscopy performed with biopsy returned negative for CMV. A repeat CT abdomen to assess the adrenals was performed 2 weeks after completion of valganciclovir. His adrenal nodules had decreased significantly in size, with his left adrenal gland nodules measuring 1 cm and now his right adrenal gland nodule measuring 1 cm.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Arthritis, Rheumatoid / drug therapy
  • Candidiasis / chemically induced*
  • Cytomegalovirus Infections / chemically induced*
  • Gastritis / chemically induced*
  • Gastritis / microbiology*
  • Helicobacter Infections / etiology*
  • Helicobacter pylori*
  • Humans
  • Immunosuppressive Agents / adverse effects*
  • Immunosuppressive Agents / therapeutic use
  • Male
  • Methotrexate / adverse effects*
  • Methotrexate / therapeutic use


  • Immunosuppressive Agents
  • Methotrexate