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Folic-acid/folinic-acid/methotrexate Methotrexate toxicity leading to pancytopenia secondary to myelosuppression and lack of efficacy: case report

A 46-year-old woman developed methotrexate toxicity leading to pancytopenia secondary to myelosuppression during treatment with methotrexate for systemic lupus erythematosus (SLE). Additionally, she exhibited lack of efficacy during treatment with folic acid and folinic acid for vitamin deficiency and pancytopenia due to methotrexate toxicity. The woman, who had SLE and severe malnutrition, presented to an emergency department with painful mouth sores and altered mental status. She was hospitalised. Her SLE had been well controlled on low-dose methotrexate for 5 years [route and dosage not stated]. Upon presentation, she exhibited severe pancytopenia with a WBC count of 1.3 × 109/L, absolute neutrophil count of 0.2 × 109/L, platelets count of 3 × 109/L and haemoglobin of 4 g/dL. Workup showed profound mineral and vitamin deficiencies. Bone marrow biopsy revealed markedly decreased haematopoiesis and extensive serous stromal necrosis. She was considered to have developed methotrexate toxicity due to increased half-life of methotrexate and significantly delayed methotrexate plasma clearance secondary to poor nutritional status. Based on the clinical picture along with vitamin deficiencies and stromal necrosis in the bone marrow (due to severe malnutrition), her pancytopenia was attributed to myelosuppression secondary methotrexate toxicity compounded by her profound malnourished state [duration of treatment to reaction onset not stated]. The woman was treated with folic acid [folate] and folinic-acid [leucovorin]; however, her blood counts failed to improve. Subsequently, she developed respiratory failure due to intra-alveolar haemorrhage, leading to her death. Bojanini Molina L, et al. Low-Dose Methotrexate Causing Fatal Pancytopenia in a Patient With Severe Malnutrition. JCR: Journal of Clinical Rheumatology : 23 Jul 2020. 803498375 Available from: URL: http://doi.org/10.1097/RHU.0000000000001501

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Reactions 29 Aug 2020 No. 1819