Pancreatitis presenting without abdominal pain is very unusual. Here we report a 70-year-old man with chronic calcific pancreatitis presented to us with prolonged fever, arthritis and multiple subcutaneous swellings, but without any abdominal pain or other abdominal symptoms. His serum amylase and lipase were very high. Biopsy from the subcutaneous swellings revealed fat necrosis and CT scan abdomen showed features of chronic calcific pancreatitis. He was managed conservatively with supportive measures, and recovered. There is only scanty information in literature regarding this type of presentation in chronic pancreatitis.
Methotrexate is one of the most commonly used drugs in autoimmune disorders like rheumatoid arthritis. Gastrointestinal symptoms like nausea and stomatitis, skin rashes, alopecia, central nervous system symptoms like headache and confusion, hepatotoxicity and myelosuppression are some of the adverse effects. However, low oral doses on a weekly basis seldom show any signs of toxicity. Leucovorin or folinic acid is given along with methotrexate as rescue to reduce the toxic effects like bone marrow suppression. Non-steroidal anti-inflammatory drugs, like aceclofenac, are also used in chronic inflammatory conditions like rheumatoid arthritis and osteoarthritis. Nephrotoxicity is one of the adverse effects of both methotrexate and non-steroidal anti-inflammatory drugs; and its combined administration should be done with caution. This is a case of an elderly woman, a known case of rheumatoid arthritis, who presented in severe bone marrow suppression due to methotrexate toxicity following aceclofenac-induced acute kidney injury.
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