SHM Converge Scientific Abstract ePoster Gallery-Joint Pain or Pancytopenia? Methotrexate Induced Pancytopenia: A Case Report

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This case report describes a 76-year-old woman with rheumatoid arthritis who presented with worsening pain, lethargy, severe oral stomatitis, and profound pancytopenia after taking low-dose methotrexate. Her initial labs showed extreme leukopenia, thrombocytopenia, anemia, acute kidney injury, and metabolic acidosis, and she also had gram-negative bacteremia and C. difficile infection. Examination revealed dry mucous membranes, diffuse oral ulcerations, ecchymoses, and hypoxemia.  <br /><br />Because methotrexate toxicity can be mistaken for other causes of illness, especially in patients with rheumatoid arthritis, the report emphasizes the importance of medication reconciliation and early recognition of warning signs such as oral mucositis and marrow suppression. Risk factors for toxicity include older age, renal dysfunction, folate deficiency, alcohol use, hypoalbuminemia, and other comorbidities.  <br /><br />During hospitalization, methotrexate and sarilumab were stopped, and she received leucovorin rescue, IV fluids, antibiotics, and supportive care. Her course was complicated by severe bleeding, including hematochezia, pulmonary hemorrhage, bowel wall hemorrhage, and iliopsoas hemorrhage. Imaging showed active bleeding near the splenic flexure, and later endoscopy revealed large duodenal ulcers that were cauterized. A bone marrow biopsy ruled out leukemia, lymphoma, and aplastic anemia.  <br /><br />After prolonged treatment, her condition gradually improved. She was able to tolerate a full diet, ambulate, and perform most activities of daily living before discharge to rehabilitation on hospital day 29. The report concludes that clinicians should promptly consider methotrexate toxicity in rheumatoid arthritis patients with unexplained mucositis or pancytopenia and immediately hold the drug while starting rescue and supportive therapy.

Asset Subtitle

Christopher DeHaven

Meta Tag

Author List Christopher DeHaven, Justin Ceasar, Nicholas S. Duca, Peter Shafeek

Category Clinical Vignettes

Concept Methotrexate

Concept Toxicity

Concept Methotrexate Toxicity

Concept Pancytopenia

Concept Mucositis

Distinguished Non-Finalist

Presenter Organization Penn State College of Medicine

Presenting Author Christopher DeHaven

Track Adult

Keywords

methotrexate toxicity

rheumatoid arthritis

pancytopenia

oral stomatitis

leucovorin rescue

renal dysfunction

medication reconciliation

gram-negative bacteremia

C. difficile infection

gastrointestinal hemorrhage

Methotrexate

Toxicity

Methotrexate Toxicity

Pancytopenia

Mucositis