Delayed elimination of methotrexate induced multiple organ dysfunction

Abstract

A 59-year-old male patient with diffuse large B-cell lymphoma received IV infusion of high-dose methotrexate (MTX) 15 g (8 g/m2). At the first treatment with an IV infusion of methotrexate about 10 min (about 0.8 g), the patient presented with dizziness, flushing, and feeling of cold. MTX was stopped and IV injection of dexamethasone 5 mg was given and 5 minutes later, the patient′s symptoms were improved. The IV infusion of MTX was continued and about 10 minutes later, the patient developed the above-mentioned symptoms again. MTX was stopped again. At the second treatment with the same dose of methotrexate about 10 min (about 0.8 g), the above-mentioned symptoms recurred and relieved after MTX withdrawal and symptomatic treatments. On the 5th day after MTX withdrawal, the patient presented with erythema on buttocks and sacrum, bullous rash on chest, and throat ache and the MTX serum concentration was 0.38 μmol/L. On the 6th day after MTX withdrawal, the patient presented with high temperature (39.5 ℃), white blood cell count 0.36×109/L, neutrophil 0.22×109/L, serum creatinine 151 μmol/L and positive fecal occult blood test. It was suspected that MTX induced allergy and delayed elimination of MTX induced multiple organ injuries. IV infusion of leucovorin was given at a dose of 100 mg every 6 h. Meanwhile, anti-allergy, anti-infection, and nutritional supportive treatments were given. On the 14th day after MTX withdrawal, erythema disappeared and serum creatinine was 96 μmol/L. On the 26th day after MTX withdrawal, white blood cell count was 6.34×109/L, neutrophil was 4.77×109/L, and fecal occult blood test was negative. Key words: Methotrexate; Erythema; Leukopenia; Renal insufficiency