Worsening of Felty's syndrome with methotrexate.

worsening of neutropenia. A 55 year old man had had rheumatoid arthritis since 1980. He had received second line drug treatment, including gold compounds and D-penicillamine, which were discontinued because of proteinuria and inefficacy respectively. Haematological signs of toxicity were not noted with these treatments. A diagnosis of Felty's syndrome was established in 1988 when he developed a splenomegaly associated with polyarthritis and was found to have neutropenia (white blood cells 2-41 x I09/l; neutrophils 0-72x109/l). Prednisone treatment 30 mg daily was started, then decreased to 20 mg/daily. In December 1989 he presented with acute polyarthritis and low peripheral neutrophils at 1 76x I09/l. The erythrocyte sedimentation rate was 45 mm/h. Methotrexate 7-5 mg weekly was introduced, together with 15 mg prednisone daily. After one month no marked amelioration of clinical condition was seen, the spleen was unchanged, white blood cells control showed a drop of neutrophils to 1-036x109/l (WBC 2 8x109/l, platelets 231x109/l). Methotrexate was discontinued. Further follow up showed that after one month neutrophils had increased and stabilised. Treatment with corticosteroids was continued alone. In this patient methotrexate treatment failed to improve Felty's syndrome, and, on the contrary, induced a transient worsening of neutropenia. His condition was well defined,4 and no previous history of toxic neutropenia was found. He was not receiving any other neutropenic drug. His condition did not apparently differ from those of other patients who improved with methotrexate treatment.`3 Our data suggest individual sensitivity to methotrexate treatment in Felty's syndrome, and further studies are needed to define the characteristics which would predict