Grade 4 oral mucositis and prolonged pancytopenia with high dose intravenous methotrexate in a patient of philadelphia positive acute lymphoblastic leukemia
Keywords:
Methotrexate (MTX), Mucositis, Pancytopenia, ALLAbstract
Antimetabolite drugs are rarely associated with grade 3 or 4 mucositis. However specific side effects such as bone marrow suppression, pancytopenia, hospitalization, high cost limit the use of intravenous methotrexate. Here we report a case of 25-year-old girl patient with Acute Lymphoblastic Leukemia (ALL) treated with 24 hour methotrexate in her continuous phase of chemotherapy. After 12 hours of completing the treatment she developed oral mucosal pain & she was not able to speak. After a week, her White Blood Cell (WBC) count was 600/cumm with fever and she could not speak and eat or drink. So she was hospitalized for few days till she can drink something. We report high grade mucositis with methotrexate. Hematologists should be aware of this possible side effect to undertake early intervention.
References
Methotrexate. Available at http://www.medicinenet.com/methotrexate-injection/article.html. Accessed 25 July 2012.
National Institutes of Health. Methotrexate injection. Available at http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682018.html#other-uses. Accessed on 25 July 2012.
Methotrexate side effects. Available at http://www.drugs.com/sfx/methotrexate-side-effects.html. Accessed 25 July 2012.
Boukhettala N, Leblond J, Claeyssens S, Faure M, Le Pessot F, Boˆle-Feysot C, et al. Methotrexate induces intestinal mucositis and alters gut protein metabolism independently of reduced food intake. Am J Physiol Endocrinol Metab 2009; 296:E182-E190.
Ridge JA, Glisson BS, Lango MN, et al. "Head and Neck Tumors" in Pazdur R, Wagman LD, Camphausen KA, Hoskins WJ (Eds). Cancer Management: A Multidisciplinary Approach. 11 ed. 2008.
Naidu MU, Ramana GV, Rani PU, Mohan IK, Suman A, et al. Chemotherapy-induced and/or radiation therapy-induced oral mucositis-complicating the treatment of cancer. Neoplasia 2004; 6:423-31.
Sonis ST. The pathobiology of mucositis. Nat Rev Cancer 2004; 4:277-84.
Logan RM, Stringer AM, Bowen JM, Gibson RJ, Sonis ST, et al. Is the pathobiology of chemotherapy-induced alimentary tract mucositis influenced by the type of mucotoxic drug administered? Cancer Chemother Pharmacol 2009; 63:239-51.
Bitran JD, Samuel B, Klein L, Hanauer S, Johnson L, Martinec J, Harris E, Kempler J, White L. Random high dose chemotherapy supported by hematopoietic progenitor cells yields prolonged survival in stage IV breast cancer. Bone Marrow Transplant 1996; 17:157-62.
Tripathi KD. Antimetabolites. Essentials of Medical Pharmacology, 6th ed. New Delhi: Jaypee brothers; 2008:823.
Keefe DM, Brealey J, Goland GJ, Cummins AG. Chemotherapy for cancer causes apoptosis that precedes hypoplasia in crypts of the small intestine in humans. Gut 2000; 47:632-7.
Ballinger A, El-Haj T, Perrett D, Turvill J, Obeid O, Dryden S, et al. The role of medial hypothalamic serotonin in the suppression of feeding in a rat model of colitis. Gastroenterology 2000; 118:544-53.
Oral Mucositis. Available at http://painconsortium.nih.gov/symptomresearch/chapter_17/sec7/cghs7table71pop1.htm. Accessed on 25 July 2012.
Muscaritoli M, Grieco G, Capria S, Iori AP, Rossi Fanelli F. Nutritional and metabolic support in patients undergoing bone marrow transplantation. Am J Clin Nutr 2002; 75:183-90.
