Successful Methotrexate Treatment in a Patient with Steroid Resistant Myocardial Sarcoidosis

Abstract

A 70-years-old woman complaining blurred vision in December 1997 consulted to our ophthalmologist, who made the diagnosis of bilateral uveitis. Her serum level of lysozyme and ACE were elevated, PPD skin test was negative. Chest X-ray film revealed bilateral hilar lymphadenopathy which had been never seen before.
ECG disclosed complete right bundle brunch block (CRBBB) which had also been never recognized before. She had been managed for essential hypertention 5 years before the onset with uveitis. Skin biopsy from the right knee revealed epithelioid cell granuloma.
As myocardial sarcoidosis was suspected, coronary angiography and myocardial biopsy was performed. These procedures failed to show neither ischemic change of coronary arteries nor epithelioid cell granuloma. ²⁰¹Tl myocardial scintigram showed some defect of myocardial uptake. We diagnosed clinically myocardial sarcoidosis based on the diagnostic criteria.
Corticosteroid therapy including steroid pulse therapy failed to improve ECG findings. Then the prolonged use of low-dose methotrexate (MTX, 5mg a week) was added to corticosteroid in May 1998. The CRBBB disappeared after 6 month's treatment with MTX, and by that time the dose of prednisolone had been reduced to 10mg a day at that time.
The prolonged low-dose MTX therapy was useful for the management of steroid resistant myocardial sarcoidosis.