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Bowel perforation due to methotrexate therapeutic error: an insidious adverse reaction

M Cirronis1, E Novara, T Persiano

  • 1Toxicology Unit, Pavia Poison Centre and National Toxicology Information Centre, Laboratory  of Clinical and Experimental Toxicology, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy. marco.cirronis@icsmaugeri.it.

European Review for Medical and Pharmacological Sciences
|March 23, 2021
PubMed
Abstract

Insights

A rare but severe adverse effect of methotrexate (MTX) is bowel perforation, which can occur with incorrect daily dosing instead of weekly. This case highlights the critical importance of correct MTX administration to prevent potentially fatal outcomes.

Area of Science:

  • Rheumatology
  • Gastroenterology
  • Clinical Toxicology

Background:

  • Methotrexate (MTX) is a cornerstone therapy for various rheumatic and non-rheumatic conditions.
  • Therapeutic errors, particularly incorrect dosing schedules, can lead to severe adverse events.
  • Bowel perforation is an exceptionally rare but life-threatening complication of MTX therapy.

Observation:

  • A 68-year-old male patient with rheumatoid arthritis inadvertently took 7.5 mg of MTX daily instead of weekly.
  • Within 10 days, he developed symptoms including mucositis, thrombocytopenia, and malaise.
  • Clinical deterioration prompted an emergency CT scan, revealing bowel perforation.

Findings:

  • The patient underwent emergency surgery for bowel perforation (sigma resection).
  • Histopathological examination confirmed MTX toxicity as the cause of the perforation.
  • Prompt treatment with Leucovorin and urine alkalinization was initiated.

Implications:

  • This case underscores the critical need for patient education regarding MTX dosing to prevent severe toxicity.
  • Reinforces the importance of vigilant monitoring for adverse effects in patients receiving MTX.
  • Highlights the potential for gastrointestinal perforation as a rare but serious consequence of MTX dosing errors.

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