Pancytopenia, mucositis, and hepatotoxicity after intralesional methotrexate injection in a patient treated with peritoneal dialysis

Abstract

A 68-year-old peritoneal dialysis patient who was treated with 25 mg of intralesional methotrexate for squamous cell carcinoma of the hands developed pancytopenia, mucositis, and hepatotoxicity as a result of systemic absorption and prolonged elimination.

Neoadjuvant intralesional methotrexate in cutaneous squamous cell carcinoma: a comparative cohort study

“…Locally, infiltration achieves higher MTX intracellular concentration in cSCC cells, which are >10 4 times more sensitive to the cytotoxic effect of MTX . The success shown by MTX–il in the treatment of keratoacanthomas both as monotherapy and neoadjuvant to surgery has led to various authors using it in some cSCC cases …”

“…Contrary to the published articles, more than half of our patients showed mild discomfort during infiltration, however, administration of local anaesthesia or any other intervention were not required. The prior determination of kidney function in patients avoided the possible development of pancytopenia due to the MTX–il, as the cases observed in the literature occurred in patients under dialysis …”

Development of pancytopenia after single low-dose methotrexate therapy in patients with chronic kidney disease: a review of the literature

“…In some patients, the MTX concentration was very high (range: 0.06-0.53 μmol/L)1 8,31-33,37,38,41 , while in others it was measured normal (0.005 μmol/L) 29 or slightly high (range: 0.02-0.03 μmol/L). 34,36,40,42 In our cases, MTX level could not be measured. Really, myelosuppression may become evident in the setting of prolonged elevated serum levels of MTX.…”

Successful multiple-exchange peritoneal dialysis in a patient with severe hematological toxicity by methotrexate: case report and literature review

“…The literature reports several cases of pancytopenia in patients on dialysis after therapy with low doses of methotrexate, even with intralesional application; these cases were published between 1990 and 2017 11 , 25. Liu WC and colleagues reported 1 case and collected another 15 cases from 12 publications in the literature;15 we found another 3 cases published,22 , 24 and with this case report, we have a total of 20 cases reported with diagnosis of pancytopenia associated with methotrexate in patients on dialysis (see table 2).…”

“…There are reports of methotrexate removal by hemodialysis and hemoperfusion, with both methods effectively removing the drug thanks to its binding to proteins by 50%. However, there is a post-dialysis rebound in the methotrexate concentration of 90-100% to the levels prior to the procedure; therefore, patients may require daily or continuous renal replacement therapy to avoid rebound toxicity 25. However, little is known about removal by peritoneal dialysis.…”