Successful multiple-exchange peritoneal dialysis in a patient with severe hematological toxicity by methotrexate: case report and literature review / Diálise peritoneal com múltiplas trocas bem-sucedida em paciente com grave toxicidade hematológica por metotrexato: relato de caso e revisão de literatura

Abstract Methotrexate is an effective medication to control several diseases; however, it can be very toxic, being myelosuppression one of its main adverse effects, which increases in severity and frequency in patients with renal failure. We present the case of a 68-year-old man with chronic, end-stage renal disease associated with ANCA vasculitis, under treatment with peritoneal dialysis, who received the medication at a low dose, indicated by disease activity, which presented as a complication with severe pancytopenia with mucositis that improved with support measures and multiple-exchange peritoneal dialysis. We reviewed 20 cases published to date of pancytopenia associated with methotrexate in patients on dialysis and found high morbidity and mortality, which is why its use in this type of patient is not recommended. However, when this complication occurs, a therapeutic option could be the use of multiple-exchange peritoneal dialysis in addition to supportive therapy for drug-related toxicity, although it is recognized that studies are required to show the role of multiple-exchange peritoneal dialysis in the removal of this medication.

Resumo Apesar de sua toxicidade, o metotrexato é um medicamento eficaz no controle de várias doenças. A mielossupressão, um de seus principais efeitos adversos, aumenta em gravidade e frequência nos pacientes com insuficiência renal. Apresentamos o caso de um homem de 68 anos de idade com doença renal terminal relacionada à vasculite associada ao ANCA em diálise peritoneal, que recebeu a medicação em dose baixa em função da atividade da doença e que teve como complicação pancitopenia grave com mucosite, tratada com medidas de suporte e diálise peritoneal com múltiplas trocas. Revisamos 20 casos publicados até o presente momento sobre pancitopenia associada a metotrexato em pacientes em diálise. Foi identificada alta morbidade e mortalidade, razão pela qual seu uso nesse tipo de paciente não é recomendado. No entanto, quando esta complicação ocorre, uma opção terapêutica pode ser o uso de diálise peritoneal com múltiplas trocas, além da terapia de suporte para toxicidade medicamentosa. Maiores estudos são necessários para demonstrar o papel da diálise peritoneal com múltiplas trocas na remoção desse medicamento.

Combined acute interstitial pneumonitis and pancytopenia induced by low-dose methotrexate in a hemodialysis patient treated for bullous pemphigoid

Methotrexate has been widely used for many years in the treatment of a variety of diseases. Acute pneumonitis and bone marrow suppression are very serious side effects in methotrexate treatment. A 48-year-old man with end-stage renal disease undergoing chronic hemodialysis developed combined acute pneumonitis and pancytopenia after a cumulative dose of 20 mg methotrexate for bullous pemphigoid. Continuous renal replacement therapy (CRRT) can effi ciently decrease serum methotrexate concentration. A rapid improvement of clinical symptoms and resolution of pulmonary opacifi cation were found after CRRT. Blood cell counts returned to normal after component blood transfusion and cytokine supportive therapy. Patients with impaired renal function are at high risk of methotrexate toxicity, and low-dose methotrexate should be prescribed with great caution.

Four year old child with breakthrough varicella leading to pancytopenia

A previously healthy 4-year old child received Varicella Zoster Vaccine 12 weeks prior to presentation. He developed breakthrough varicella which was complicated by pancytopenia which was refractory to all modalities of treatment necessitating Bone Marrow Transplantation

Pancitopenia en un canino ocasionada por la administración de estrógenos para evitar una preñez no deseada / Pancytopenia in a canine caused for administration of estrogens to avoid a not wanted pregnancy

Objetivo. Presentar el caso clínico de una paciente canina pancitopenica debido al uso indebido de estrógenos como método anticonceptivo. Materiales y métodos. Paciente canina de raza Poodle de 8 años, la cual fue llevada a consulta por presentar decaimiento, inapetencia, hemorragias petequiales e hipema. Resultado. Una vez realizada la anamnesis, el examen físico y los exámenes paraclínicos así como la evolución del cuadro clínico se demostró la intoxicación estrogénica exógena como diagnóstico definitivo. Conclusiones. El uso de estrógenos como método para la terminación de preñez en perras no está recomendado o considerado ético para muchos autores o asociaciones veterinarias por varias razones como: una dosis de estrógenos aparentemente efectiva no se ha establecido, por lo que su administración puede resultar en enfermedad uterina; dosis de estrógenos aparentemente seguras fueron determinadas como inseguras, y dosis aparentemente efectivas produjeron enfermedad uterina. La aplasia medular es un resultado común de la intoxicación estrogénica y esta puede conducir incluso a la muerte del paciente.

Aplasia medular tratada exitosamente con ciclosporina en un paciente en hemodiálisis crónica / Bone marrow aplasia during hemodialysis successfully treated with cyclosporine: report of one case

A 28 years old male on chronic hemodialysis for 40 months due to a IgA crescentic glomerulonephritis developed pancytopenia (hematocrit 16 percent, white blood cell count 3.800 mm3 and platelets 11.000 mm3. The bone marrow aspirate showed erythropoietic hyperplasia. Hemolytic anemia, folate or vitamin B12 deficiency and paroxysmal nocturnal hemoglobinuria were ruled out. Steroids were given with a transient elevation of red cells and platelets, which lasted only for some weeks. Afterwards, intravenous immunoglobulin was given without benefit. Two months after, a bone marrow biopsy and a bone marrow magnetic resonance imaging showed severe aplasia. Cyclosporine was started with a rapid increase in blood cells count. Eight months later, he received a renal transplant from a cadaveric donor. Immunosupression was achieved with cyclosporine, prednisone and mycofenolate mofetil. The patient required hemodialysis for the first three weeks and a mild acute cellular rejection was treated with methylprednisolone. At discharge, 6 weeks later, serum creatinine was 2.4 mg/dl and creatinine clearance 37.6 ml/min. During the first months after transplant, platelet count and hemoglobin decreased and a bone marrow biopsy showed only mild hypoplasia. Four months after renal transplant the hematocrit was 43 percent, white blood cell count 6.600 mm3 and platelets, 150.000 mm3 and did not change during the first year of follow up (Rev Méd Chile 2004; 132: 989-94).

Visceral leishmaniasis: a rare cause of post-transplant fever and pancytopenia.

Despite the endemic distribution of visceral leishmaniasis in certain parts of our country, there are only a few reports of this infection in renal transplant recipients. We report one renal transplant recipient from non-endemic area with visceral leishmaniasis and graft dysfunction that responded to treatment with stibogluconate. The infection should be considered in the differential diagnosis of a febrile transplant recipient with pancytopenia and allograft dysfunction.

Diagnóstico e tratamento de complicaçöes agudas do transplante de células progenitoras hematopoéticas / Diagnosis and treatment of acute complications of hematopoietic stem cell transplantation

Nesta revisäo, säo discutidos os princípios do diagnóstico e tratamento das principais complicaçöes agudas, näo infecciosas, do transplante de células progenitoras hematopoéticas: pancitopenia, incompatibilidade no sistema ABO, mucosite, doença veno-oclusiva hepática, cistite hemorrágica, penumonite intersticial, cardiotoxicidade e doença do enxerto-contra-hospedeiro aguda. Oito casos clínicos, extraídos da casuística da nossa Unidade de TMO, säo descritos brevemente para ilustrar aspectos particulares das doenças discutidas no trabalho.