High-dose methotrexate-related pneumonitis in a child with acute lymphoblastic leukemia
Rim Rakez1, Wiem Boufrikha1, Areej Cheffaï1
1Department of Hematology, 314309Fattouma Bourguiba Hospital of Monastir, Monastir, Tunisia.
Introduction:
Methotrexate is administered through different routes to treat childhood acute lymphoblastic leukemia. Toxicities of low, intermediate, or high doses of methotrexate have been described in the literature. Methotrexate-induced or related pneumonitis is a rare complication that leads, in most cases, to discontinuing this drug.
Case Report:
We report a case of a 17-year-old female patient with newly diagnosed B-acute lymphoblastic leukemia who received a high-dose methotrexate on an induction course. Eight days after methotrexate infusion, she developed fever, dyspnea, hypoxemia, and dry cough. Chest computed tomography showed mosaic attenuation of lung parenchyma and bilateral interstitial infiltrate in favor of hypersensitivity pneumonitis with no evidence of bacterial or fungal infections.
Management And Outcome:
Methotrexate-related pneumonitis was diagnosed and corticosteroids were prescribed. Improvement of the symptomatology was noted within four days. Given the importance of methotrexate in the treatment of acute lymphoblastic leukemia, intrathecal methotrexate was administered without incident and high-dose methotrexate was re-introduced successfully two and a half months after the pneumonitis episode while using corticosteroids. According to Naranjo's algorithm, the reaction to the drug was found to be probable with a score of 6.
Discussion:
Methotrexate is the backbone of acute lymphoblastic leukemia treatment, but numerous adverse reactions have been published of which methotrexate pneumonitis can be fatal in some cases. In this case, we concluded that this drug can be successfully reintroduced after methotrexate-related pneumonitis.
Insights
High-dose methotrexate can be safely reintroduced in pediatric acute lymphoblastic leukemia patients after experiencing methotrexate pneumonitis, a rare but serious adverse reaction. This management strategy allows continued essential treatment for leukemia.
Area of Science:
- Pediatric Oncology
- Pulmonology
- Pharmacology
Background:
- Methotrexate is a critical component in treating childhood acute lymphoblastic leukemia (ALL).
- While effective, methotrexate can cause various toxicities, including rare but potentially fatal methotrexate-induced pneumonitis.
- Previous literature often suggests discontinuing methotrexate upon diagnosis of pneumonitis.
Observation:
- A 17-year-old female with newly diagnosed B-acute lymphoblastic leukemia developed acute pneumonitis with fever, dyspnea, and hypoxemia 8 days after high-dose methotrexate infusion.
- Chest CT revealed bilateral interstitial infiltrates consistent with hypersensitivity pneumonitis, excluding infectious causes.
- The patient's symptoms improved within 4 days of initiating corticosteroid treatment.
Findings:
- Methotrexate-related pneumonitis was diagnosed using Naranjo's algorithm (score 6).
- Following recovery, intrathecal methotrexate was administered without complication.
- High-dose methotrexate was successfully re-introduced two and a half months later with concurrent corticosteroid use, demonstrating successful re-challenge.
Implications:
- This case demonstrates that methotrexate can be safely re-administered in patients with a history of methotrexate-induced pneumonitis.
- Successful reintroduction of methotrexate is crucial for maintaining effective treatment for acute lymphoblastic leukemia.
- This approach offers a viable option for managing ALL while mitigating the risks associated with methotrexate pneumonitis.
More Related Videos
04:04Endobronchial Ultrasound-guided Intratumoral Injection of Cisplatin for the Treatment of Isolated Mediastinal Recurrence of Lung Cancer
Published on: February 12, 2017
08:34Proton Therapy Delivery and Its Clinical Application in Select Solid Tumor Malignancies
Published on: February 6, 2019
Related Concept Videos
01:29Pulmonary Tuberculosis I
Causative Organism
The primary infectious agent causing tuberculosis is Mycobacterium tuberculosis, a slow-growing, acid-fast, aerobic rod that exhibits sensitivity to heat and ultraviolet light. Instances of Mycobacterium bovis and Mycobacterium avium contributing to the development of TB infection are rare.
Mode of...
01:22Bone Marrow Sampling and Transplants
The transplant begins with high doses of chemotherapy and radiation treatment, which aim to destroy...