Methotrexate-induced acute cardiotoxicity requiring veno-arterial extracorporeal membrane oxygenation support: a case report
Abstract Background Methotrexate is an antifolate antimetabolite that inhibits the activity of dihydrofolate reductase by acting as a false substrate, which leads to defects of DNA synthesis, specifically the inhibition of purine and pyrimidine synthesis. Thus, methotrexate is a powerful agent for t...
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| Format: | Article |
| Language: | English |
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BMC
2022-11-01
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| Series: | Journal of Medical Case Reports |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s13256-022-03644-9 |
| _version_ | 1811208017727717376 |
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| author | Sareena Shah Kristen Haeger-Overstreet Brigid Flynn |
| author_facet | Sareena Shah Kristen Haeger-Overstreet Brigid Flynn |
| author_sort | Sareena Shah |
| collection | DOAJ |
| description | Abstract Background Methotrexate is an antifolate antimetabolite that inhibits the activity of dihydrofolate reductase by acting as a false substrate, which leads to defects of DNA synthesis, specifically the inhibition of purine and pyrimidine synthesis. Thus, methotrexate is a powerful agent for treating autoimmune diseases and cancer. In general, methotrexate is thought to be cardioprotective and reports of methotrexate-induced cardiomyopathy are rare. We present a case of methotrexate-induced severe cardiotoxicity diagnosed by exclusion of all other potential causes. Case presentation The patient was a 54-year-old Caucasian man presenting to an outside hospital with a chief complaint of abdominal pain and bloating who reported taking methotrexate up to 20 mg per week for systemic sclerosis. After a transthoracic echocardiogram found a left ventricular ejection fraction of 10% and coronary catheterization demonstrated no significant disease, he was transferred to our hospital for advanced heart failure therapies. His condition deteriorated, and he was eventually placed on veno-arterial extracorporeal membrane oxygenation. Owing to a lack of an identifiable etiology of cardiac failure, toxicology consultation recommended 24 hours of intravenous leucovorin therapy to overcome any residual and potentially cardiotoxic methotrexate still in his system. Over the next 5 days, his cardiac function improved daily, such that on day 5 of extracorporeal membrane oxygenation, he had a left ventricular ejection fraction of 40% and was able to be decannulated. Two days later, his ejection fraction improved to 60% and normal right ventricular function. Initially, his renal function improved while on extracorporeal membrane oxygenation, but over the next week deteriorated such that he required intermittent hemodialysis until hospital discharge. Conclusions After a process of elimination, the most likely cause of this patient’s acute decline and rapid recovery of bi-ventricular function was methotrexate toxicity. Leucovorin may have aided the reversal of methotrexate toxicity. |
| first_indexed | 2024-04-12T04:15:08Z |
| format | Article |
| id | doaj.art-0325829b81f04e938748471db93f4b55 |
| institution | Directory Open Access Journal |
| issn | 1752-1947 |
| language | English |
| last_indexed | 2024-04-12T04:15:08Z |
| publishDate | 2022-11-01 |
| publisher | BMC |
| record_format | Article |
| series | Journal of Medical Case Reports |
| spelling | doaj.art-0325829b81f04e938748471db93f4b552022-12-22T03:48:25ZengBMCJournal of Medical Case Reports1752-19472022-11-011611610.1186/s13256-022-03644-9Methotrexate-induced acute cardiotoxicity requiring veno-arterial extracorporeal membrane oxygenation support: a case reportSareena Shah0Kristen Haeger-Overstreet1Brigid Flynn2University of Missouri-Kansas City School of MedicineDepartment of Pharmacy, The University of Kansas Health SystemDepartment of Anesthesiology, University of Kansas Health SystemAbstract Background Methotrexate is an antifolate antimetabolite that inhibits the activity of dihydrofolate reductase by acting as a false substrate, which leads to defects of DNA synthesis, specifically the inhibition of purine and pyrimidine synthesis. Thus, methotrexate is a powerful agent for treating autoimmune diseases and cancer. In general, methotrexate is thought to be cardioprotective and reports of methotrexate-induced cardiomyopathy are rare. We present a case of methotrexate-induced severe cardiotoxicity diagnosed by exclusion of all other potential causes. Case presentation The patient was a 54-year-old Caucasian man presenting to an outside hospital with a chief complaint of abdominal pain and bloating who reported taking methotrexate up to 20 mg per week for systemic sclerosis. After a transthoracic echocardiogram found a left ventricular ejection fraction of 10% and coronary catheterization demonstrated no significant disease, he was transferred to our hospital for advanced heart failure therapies. His condition deteriorated, and he was eventually placed on veno-arterial extracorporeal membrane oxygenation. Owing to a lack of an identifiable etiology of cardiac failure, toxicology consultation recommended 24 hours of intravenous leucovorin therapy to overcome any residual and potentially cardiotoxic methotrexate still in his system. Over the next 5 days, his cardiac function improved daily, such that on day 5 of extracorporeal membrane oxygenation, he had a left ventricular ejection fraction of 40% and was able to be decannulated. Two days later, his ejection fraction improved to 60% and normal right ventricular function. Initially, his renal function improved while on extracorporeal membrane oxygenation, but over the next week deteriorated such that he required intermittent hemodialysis until hospital discharge. Conclusions After a process of elimination, the most likely cause of this patient’s acute decline and rapid recovery of bi-ventricular function was methotrexate toxicity. Leucovorin may have aided the reversal of methotrexate toxicity.https://doi.org/10.1186/s13256-022-03644-9Methotrexate toxicityAcute cardiotoxicityLeucovorin rescue |
| spellingShingle | Sareena Shah Kristen Haeger-Overstreet Brigid Flynn Methotrexate-induced acute cardiotoxicity requiring veno-arterial extracorporeal membrane oxygenation support: a case report Journal of Medical Case Reports Methotrexate toxicity Acute cardiotoxicity Leucovorin rescue |
| title | Methotrexate-induced acute cardiotoxicity requiring veno-arterial extracorporeal membrane oxygenation support: a case report |
| title_full | Methotrexate-induced acute cardiotoxicity requiring veno-arterial extracorporeal membrane oxygenation support: a case report |
| title_fullStr | Methotrexate-induced acute cardiotoxicity requiring veno-arterial extracorporeal membrane oxygenation support: a case report |
| title_full_unstemmed | Methotrexate-induced acute cardiotoxicity requiring veno-arterial extracorporeal membrane oxygenation support: a case report |
| title_short | Methotrexate-induced acute cardiotoxicity requiring veno-arterial extracorporeal membrane oxygenation support: a case report |
| title_sort | methotrexate induced acute cardiotoxicity requiring veno arterial extracorporeal membrane oxygenation support a case report |
| topic | Methotrexate toxicity Acute cardiotoxicity Leucovorin rescue |
| url | https://doi.org/10.1186/s13256-022-03644-9 |
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