Potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case report
Abstract Background Low dose methotrexate toxicity rarely occurs, but may present with severe complications, such as pancytopenia, hepatotoxicity, mucositis, and pneumonitis. Known risk factors for methotrexate toxicity include dosing errors, metabolic syndrome, hypoalbuminemia, renal dysfunction, l...
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| Format: | Article |
| Language: | English |
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BMC
2021-02-01
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| Series: | BMC Rheumatology |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s41927-020-00175-y |
| _version_ | 1831557395535364096 |
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| author | Miguel A. Jara-Palacios William Chun Nomi L. Traub |
| author_facet | Miguel A. Jara-Palacios William Chun Nomi L. Traub |
| author_sort | Miguel A. Jara-Palacios |
| collection | DOAJ |
| description | Abstract Background Low dose methotrexate toxicity rarely occurs, but may present with severe complications, such as pancytopenia, hepatotoxicity, mucositis, and pneumonitis. Known risk factors for methotrexate toxicity include dosing errors, metabolic syndrome, hypoalbuminemia, renal dysfunction, lack of folate supplementation, and the concomitant use of drugs that interfere with methotrexate metabolism. Vitamin B12 deficiency leads to megaloblastic anemia and may cause pancytopenia, but its role in methotrexate toxicity has not been described. Case presentation We present a case of a patient with rheumatoid arthritis who was admitted with febrile neutropenia, pancytopenia, and severe mucositis, likely secondary to low dose methotrexate toxicity. She had multiple factors that potentially contributed to the development of toxicity, including concurrent sulfasalazine use for rheumatoid arthritis. An evaluation of the patient’s macrocytic anemia revealed pernicious anemia. The patient’s illness resolved with cessation of methotrexate and sulfasalazine, leucovorin treatment and vitamin B12 repletion. Conclusions This case illustrates the multiple factors that may potentially contribute to low dose methotrexate toxicity and highlights the importance of testing for vitamin B12 deficiency in rheumatoid arthritis patients with macrocytic anemia. Addressing all the modifiable factors that potentially contribute to low dose methotrexate toxicity may improve outcomes. |
| first_indexed | 2024-12-17T04:50:40Z |
| format | Article |
| id | doaj.art-25e0487255b549958df2615bdba738e7 |
| institution | Directory Open Access Journal |
| issn | 2520-1026 |
| language | English |
| last_indexed | 2024-12-17T04:50:40Z |
| publishDate | 2021-02-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Rheumatology |
| spelling | doaj.art-25e0487255b549958df2615bdba738e72022-12-21T22:02:54ZengBMCBMC Rheumatology2520-10262021-02-01511610.1186/s41927-020-00175-yPotential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case reportMiguel A. Jara-Palacios0William Chun1Nomi L. Traub2Department of Internal Medicine, WellStar Atlanta Medical CenterDepartment of Internal Medicine, WellStar Atlanta Medical CenterDepartment of Internal Medicine, WellStar Atlanta Medical CenterAbstract Background Low dose methotrexate toxicity rarely occurs, but may present with severe complications, such as pancytopenia, hepatotoxicity, mucositis, and pneumonitis. Known risk factors for methotrexate toxicity include dosing errors, metabolic syndrome, hypoalbuminemia, renal dysfunction, lack of folate supplementation, and the concomitant use of drugs that interfere with methotrexate metabolism. Vitamin B12 deficiency leads to megaloblastic anemia and may cause pancytopenia, but its role in methotrexate toxicity has not been described. Case presentation We present a case of a patient with rheumatoid arthritis who was admitted with febrile neutropenia, pancytopenia, and severe mucositis, likely secondary to low dose methotrexate toxicity. She had multiple factors that potentially contributed to the development of toxicity, including concurrent sulfasalazine use for rheumatoid arthritis. An evaluation of the patient’s macrocytic anemia revealed pernicious anemia. The patient’s illness resolved with cessation of methotrexate and sulfasalazine, leucovorin treatment and vitamin B12 repletion. Conclusions This case illustrates the multiple factors that may potentially contribute to low dose methotrexate toxicity and highlights the importance of testing for vitamin B12 deficiency in rheumatoid arthritis patients with macrocytic anemia. Addressing all the modifiable factors that potentially contribute to low dose methotrexate toxicity may improve outcomes.https://doi.org/10.1186/s41927-020-00175-yLow dose methotrexate toxicityVitamin B12 deficiencyRheumatoid arthritisSulfasalazine |
| spellingShingle | Miguel A. Jara-Palacios William Chun Nomi L. Traub Potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case report BMC Rheumatology Low dose methotrexate toxicity Vitamin B12 deficiency Rheumatoid arthritis Sulfasalazine |
| title | Potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case report |
| title_full | Potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case report |
| title_fullStr | Potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case report |
| title_full_unstemmed | Potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case report |
| title_short | Potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia: case report |
| title_sort | potential contributors to low dose methotrexate toxicity in a patient with rheumatoid arthritis and pernicious anemia case report |
| topic | Low dose methotrexate toxicity Vitamin B12 deficiency Rheumatoid arthritis Sulfasalazine |
| url | https://doi.org/10.1186/s41927-020-00175-y |
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