Methotrexate (MTX) Induced Pancytopenia - A Rare Serious Adverse Effect

A 65-year-old woman presented to us with complaints of fatigability and appearance of red spots on extremities since 6 days. She was a known case of rheumatoid arthritis since 5 years and was on tablet prednisolone 5 mg OD and tablet hydroxychloroquine 200 mg bid orally. Two months back she had exaggerated symptoms in the form of increased joint pains for which tablet methotrexate 7.5 mg was started weekly once and was increased to 7.5 mg bid (15 mg) per week 2 weeks back along with folic acid 5 mg per day.Methotrexate (MTX) is a folate antagonist used to treat various malignancies, and autoimmune disorders including rheumatoid arthritis. It enters cell by an active cellular uptake and inhibits dihydrofolate reductase (DHFR) enzyme that converts dihydrofolate (DHF) to tetrahydrofolate (THF) affecting purine and ultimately DNA synthesis. Cell with capability of polyglutamylation like myeloblasts and lymphoblasts are most susceptible to the effects of MTX because polyglutamylation prolongs its intracellular presence.1,2

Sub Clinical Disease Presenting with Serious Clinical Manifestations - Blame Thyroid.

Graves' disease is responsible for 60 to 80% cases of thyrotoxicosis and characteristically presents between the ages of 20 and 50 years.Both environmental and genetic factors lead to the development of Grave’s Disease.(1) Hyperthyroidism seen in grave’s disease is caused by thyroid-stimulating immunoglobulins (TSI) that are synthesized in the thyroid gland, bone marrow and lymph nodes, and detected by direct bioassays or TSH-binding inhibiting immunoglobulin (TBII) assays. Thyroid peroxidase (TPO) antibodies are found in about 80% of cases suggestive of Grave’s Disease.(1) Grave Disease is known to have multiple serious complications like Hypokalemia, Thrombocytopenia, heart rhythm abnormalities, brittle bone and thyroid storm(1,2). Hypokalemia in Grave’s Disease is a rare life-threatening complication seen, mostly in young males, often presents acute onset paraparesis. Paralytic symptoms usually occur after heavy exercise or carbohydrates rich meal.(3)This case report highlights about a young man who presented with quadriparesis, later on investigation diagnosed as hypokalemia due to subclinical grave’s disease.Clinically silent Grave’s Disease presenting with neurological quadriparesis is diagnostic challenge. Neurological paresis rapidly resolves with correction of hypokalemia. This report discusses the case of young man who presented with acute onset quadriparesis without any clue, came out as hypokalemic due to subclinical grave’s disease.

Pseudocyst of Pancreas, Rare Crisis in Sickle Cell Disease.

Sickle cell syndrome is an inherited autosomal recessive disease which results in the production of abnormal haemoglobin S due to a point mutation in the beta globin gene that changes the sixth amino acid from glutamic acid to valine (α2β2 6 Glu→Val).[1] These deformed RBCs cause vaso-occlusion, tissue ischemia, and infarction leading to clinical manifestations. About 10% of sickle cell patients present with acute abdominal pain, which may be due to acute cholecystitis, acute pancreatitis (rare), peptic ulcer disease, constipation due to opioids, hepatic and splenic sequestration, urinary tract infections and ischaemic bowel.[2,3,4]On literature search, not a single case of pseudo pancreatic cyst as a complication of sickle cell disease has been reported. We present a rare case of vaso-occlusive crisis in a 40 year old male patient with sickle cell anaemia leading to acute ischemic pancreatitis which may not be identified at initial stages as he was treated with fluids for sickle cell crisis similar to acute pancreatitis later on diagnosed as pseudo cyst pancreas.Pancreatic pseudocyst in a sickle cell disease is commonly misdiagnosed as sickle cell crisis hence causing difficulty in establishing the diagnosis, especially if abdominal pain is the presenting complaint. We present a case of 40-year-old non-alcoholic male having complaints of pain abdomen, misdiagnosed as peptic ulcer disease turned out to be pseudocyst of pancreas on ultrasonography of abdomen.