To the Editor:
The article by Derot and colleagues1 describes a 60-year-old woman with rheumatoid arthritis (RA) who developed 4 pulmonary nodules taking methotrexate (MTX) therapy1. MTX was discontinued. Because of uncontrolled synovitis, the patient was started on etanercept monotherapy. The authors documented marked improvement of the pulmonary nodules 21 months after the initiation of etanercept and further improvement later on. The article does not specify when exactly MTX was discontinued, but it appears this was not long before etanercept was started. The authors conclude that the etanercept likely led to shrinkage of the pulmonary nodules. In their discussion an obvious alternative conclusion was not mentioned: that the mere discontinuation of methotrexate led to the observed improvement in the pulmonary nodules. Marked improvement of rheumatoid nodules after discontinuation of MTX has been well documented2 and, in my own clinical experience, can be quite dramatic. Any inference about possible clinical benefit for rheumatoid nodules related to etanercept therapy needs to be strongly cautioned.