Thanks,Luis,

I have not initiated MTX as yet. Need advice on its use in this patient. 

Are you sure of the diagnosis of chronic CMV hepatitis? Was there evidence of CMV infection on the liver biopsy? 

Thanks for your response. The diagnosis of CMV hepatitis was made about 10 years ago by a Gastro-enterologist. I have no written documentation in this regard except for the patients verbal report. Her CMV IgG is positive. Her liver biopsy showed aggregates of neutrophil polymorphonuclear leukocytes within the hepatocytes and  immunohistochemical staining showed basophilic cytoplasmic granularity suggestive of CMV hepatitis. However, viral inclusion bodies were not demonstrated. The rest of the liver architecture was normal. There was no evidence of cirrhosis. 

Were the slides interpreted by an expert liver pathologist? If not, I would suggest having the slides reviewed by one. Chronic CMV hepatitis is an uncommon diagnosis. Was she ever treated for CMV, and did her liver biochemistries improve on treatment?

The slides were reported by a general histo-pathologist.  I will request that the slides be reviewed by a expert liver pathologist- locally or abroad. According to the patient     " she was treated for CMV hepatitis" no further details are available. Unfortunately, the gastro-enterologist is long gone. Cumulative LFT's over the last 3 years from the patient's GP showed a persistently elevated ALT and AST ( 2.5 x ULN) . 

I recommend you take new liver biopsy and detection of viral DNA by PCR. All immunosuppressive treatments (Biological and non biological) are contraindicated in any active viral disease, or administering therapeutic vs CMV prior to treatment of RA because if this very symptomatic, the  inflammatory response could have been ignited by CMV infection

Thanks. Please see above. The patient has NOT been on any immuno- suppressive therapy. 

Please see response to Prof  Luis Rodrigo yesterday: METHOTREXATE HAS NOT BEEN INITIATED IN THIS PATIENT.

My dilemma is that is a plausible history of CMV hepatitis, no signs of chronic liver disease or portal hypertension clinically, transaminitis on biochemistry with a liver biopsy "suggestive" of CMV hepatitis but NO features of chronic liver disease or cirrhosis on histology. 

See responses to Prof  Tai. No other viral infections from history or serology.

Thanks

Methotrexate has immunosuppressive properties.It is contraindicated in arthritis. I have published many papers on cytotoxic effects of methotrexate.