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- Two Cases of Severe Pancytopenia Associated with Low-Dose Methotrexate Therapy in Patients with Chronic Kidney Disease and Rheumatoid Arthritis.
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Hong Ik Kim, Woo Hyun Lee, Jang Seok Oh, Hyo Rim Hong, In Hee Lee
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Yeungnam Univ J Med. 2011;28(1):60-69. Published online June 30, 2011
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DOI: https://doi.org/10.12701/yujm.2011.28.1.60
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Abstract
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- Due to its efficacy and tolerability, low dose oral methotrexate(MTX) therapy has been widely used for treatment of rheumatoid arthritis(RA). However, it can rarely cause serious, life-threatening hematologic toxicities, such as pancytopenia. We report here on two patients with chronic kidney disease(CKD), who developed severe pancytopenia after 5 years (cumulative dose 1,240mg) and 4 years(cumulative dose 1,320mg) of low dose MTX therapy for treatment of RA, respectively. Both patients presented with renal insufficiency, hypoalbuminemia, concurrent use of nonsteroidal anti-inflammatory drugs, and elevated mean corpuscular volume of red blood cells(RBCs), all of which are known as risk factors of MTX-induced pancytopenia. Despite receiving treatment, which included RBC and platelet transfusions, antibiotic therapy, granulocyte colony stimulating factor, and leucovorin rescue, one patient died of sepsis. Based on our case study, prompt investigation of risk factors associated with MTX toxicity is required for all patients receiving MTX therapy. MTX treatment, even at a low dose, should be discontinued in patients with advanced CKD.
- Intrathecal Methotrexate Induced Neurotoxicity in Children with Acute Lymphoblastic Leukemia
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Jae Min Lee, Han Ku Moon, Jeong Ok Hah
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Yeungnam Univ J Med. 2007;24(2 Suppl):S761-769. Published online December 31, 2007
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DOI: https://doi.org/10.12701/yujm.2007.24.2S.S761
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Abstract
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- Central nervous system (CNS) prophylaxis is an essential component of the treatment in childhood acute lymphoblastic leukemia (ALL). Methotrexate (MTX) is an dispensable antimetabolite for treatment of ALL. High-dose (HD) MTX and intrathecal (IT) MTX have improved the prognosis and reduced the rate of CNS relapse. However, the drug also has a significant toxic effect on the CNS and can potentially lead to severe neurologic morbidity. The overall incidence of acute MTX induced neurotoxicity has been estimated to be 0.8∼10% of treated children, depending on the amounts of MTX and leucovorin in the treatment protocol. Acute neurotoxicity generally develops within 5∼14 days after IT MTX or HD MTX and may include headache, nausea, emesis, lethargy, altered mental status, blurred vision, aphasia, hemiparesis, and seizure. Diffusion weighted MRI shows restricted diffusion of water in brains of patients with ALL who experienced stroke-like event after IT MTX. We report the cinical and imaging findings of acute neurotoxicity in two patients after intrathecal administration of MTX for CNS prophylaxes of ALL.
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