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Case Reports
. 2025 Jan 21;17(1):e77754.
doi: 10.7759/cureus.77754. eCollection 2025 Jan.

Fatal Neutropenia Sepsis Following Acute Methotrexate Toxicity

Nicholsan Jesiah  1 , Yathukulan Siva  1 , Sundaresan Kt  2
Affiliations
Case Reports

Fatal Neutropenia Sepsis Following Acute Methotrexate Toxicity

Nicholsan Jesiah et al. Cureus. .

Abstract

Methotrexate (MTX) is widely used to manage autoimmune diseases such as rheumatoid arthritis, psoriasis, and eczema due to its anti-inflammatory and immunosuppressive properties. We present the case of a 69-year-old male individual with stage 3b chronic kidney disease (CKD) and diabetes mellitus, who developed acute MTX toxicity following a dosing error. The patient, prescribed MTX 7.5 mg weekly for chronic lower leg eczema, mistakenly took 5 mg every eight hours for four days. He presented with erythematous rashes, oral mucosal ulcerations, and pancytopenia, later diagnosed as neutropenic sepsis. Management included discontinuation of MTX, intravenous folinic acid, granulocyte-macrophage colony-stimulating factor (GM-CSF), and broad-spectrum antibiotics. By day 7, his blood counts and symptoms improved, and he was discharged on day 12. This case underscores the importance of patient education on proper MTX dosing to prevent life-threatening complications, particularly in high-risk populations such as the elderly and those with CKD.

Keywords: granulocyte-macrophage-colony-stimulating factor (gm-csf); methotrexate; psoriasis; rheumatoid arthritis; toxicity.

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Conflict of interest statement

Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Oral mucosal inflammation with bleeding and ulceration.
Figure 2
Figure 2. Erythematous lesions over the lower limb with scaling and ulceration.
Figure 3
Figure 3. Bilateral kidneys show hyperechoic renal cortex with altered corticomedullary demarcation favors chronic kidney disease.
See this image and copyright information in PMC

References

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