A rare side effect of methotrexate therapy: drug-induced osteopathy with multiple fractures of the lower limb.

Methotrexate is associated with bone lesions that are rare and, although presenting with a typical localisation to the lower extremities and appearing with a characteristic radiologic morphology, largely unknown and often misdiagnosed as osteoporotic insufficiency fractures. The correct and early diagnosis, however, is key for treatment and prevention of further osteopathology. Here, we present a patient with rheumatoid arthritis who developed multiple painful insufficiency fractures in the left foot (processus anterior calcanei, tuber calcanei) and in the right lower leg and foot (anterior and dorsal calcaneus and at the cuboid and distal tibia) during therapy with methotrexate, which were all misdiagnosed as osteoporotic. The fractures occurred between 8 months and 35 months after starting methotrexate. Discontinuation of methotrexate resulted in rapid pain relief and no further fractures have occurred. This case powerfully demonstrates the importance of raising awareness of methotrexate osteopathy in order to take appropriate therapeutic measures, including and perniciously discontinuing methotrexate.

Emicizumab in the Treatment of Acquired Haemophilia: A Case Report.

The prognosis of acquired haemophilia A (AHA) is severe and treatment options are limited. Emicizumab is a novel bispecific humanized monoclonal antibody in the treatment of inherited AHA with inhibitors. An 83-year-old AHA patient with congestive heart failure and a high risk for thromboembolic and cardiac events who had initially been treated successfully with steroids and substitution of recombinant B-domain-deleted porcine FVIII developed severe bleeding complications and a secondary increase in inhibitor titres after 4 weeks of treatment. Conventional therapeutic strategies failed, and the patient was subsequently treated with emicizumab on off-label and named patient use premises. After the application of emicizumab, the clinical conditions stabilized and no further substitution of coagulation factors was needed. The patient could be discharged and survived 36 days in a cardiac rehabilitation centre without indications for spontaneous bleeding or thromboembolic events. We suggest that the effects of emicizumab in acquired haemophilia should be evaluated in clinical trials.