Academic Journal
Fatal intoxication caused by conventional-dose methotrexate in an elderly patient with end-stage renal disease: A cautionary case report.
| Τίτλος: | Fatal intoxication caused by conventional-dose methotrexate in an elderly patient with end-stage renal disease: A cautionary case report. |
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| Συγγραφείς: | He Q; Department of Emergency, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China., Huang X; Department of Emergency, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China. |
| Πηγή: | Medicine [Medicine (Baltimore)] 2026 Aug 21; Vol. 105 (34), pp. e50331. |
| Τύπος έκδοσης: | Journal Article; Case Reports |
| Γλώσσα: | English |
| Στοιχεία περιοδικού: | Publisher: Lippincott Williams & Wilkins Country of Publication: United States NLM ID: 2985248R Publication Model: Print Cited Medium: Internet ISSN: 1536-5964 (Electronic) Linking ISSN: 00257974 NLM ISO Abbreviation: Medicine (Baltimore) Subsets: MEDLINE |
| Imprint Name(s): | Original Publication: Hagerstown, Md : Lippincott Williams & Wilkins |
| Ιατρικοί όροι (MeSH): | Methotrexate*/administration & dosage , Methotrexate*/adverse effects , Methotrexate*/poisoning , Methotrexate*/blood , Kidney Failure, Chronic*/complications , Antirheumatic Agents*/administration & dosage , Antirheumatic Agents*/adverse effects, Arthritis, Rheumatoid/drug therapy ; Arthritis, Rheumatoid/complications ; Multiple Organ Failure/chemically induced ; Humans ; Male ; Aged ; Fatal Outcome |
| Περίληψη: | Rationale: Methotrexate (MTX) is a first-line agent for rheumatoid arthritis, and impaired renal excretion drastically elevates the risk of fatal drug accumulation. End-stage renal disease (ESRD) patients face an extreme toxicity risk even under conventional low-dose MTX, yet related fatal cases remain underreported. This case highlights critical clinical warnings for rheumatologists and emergency physicians. Patient Concerns: A 71-year-old male with a 5-year history of rheumatoid arthritis and 1-year untreated chronic kidney disease stage 5 received weekly 10 mg subcutaneous MTX for 3 consecutive weeks without folic acid supplementation or regular laboratory monitoring. One day after his latest injection, he developed persistent nausea, vomiting, extensive oral ulcers, a skin rash, and drowsiness. Diagnoses: Severe MTX intoxication complicated by profound bone marrow suppression, septic shock, and multiple organ dysfunction syndrome. Persistently elevated serum MTX confirmed impaired renal drug clearance in ESRD. Interventions: Immediate MTX discontinuation, leucovorin calcium rescue, continuous renal replacement therapy, broad-spectrum anti-infection treatment, blood product transfusion, and invasive mechanical ventilation for progressive circulatory and respiratory failure. Outcomes: Serial serum MTX remained elevated 6 days after the final dose. Despite full intensive supportive care, the patient died of refractory septic shock and irreversible multiorgan failure. Lessons: Conventional-dose MTX is contraindicated for ESRD patients. Mandatory pre-prescription renal function assessment, regular laboratory monitoring, and folate supplementation are essential to prevent life-threatening MTX toxicity in high-risk elderly populations. (Copyright © 2026 the Author(s). Published by Wolters Kluwer Health, LLC.) |
| Competing Interests: | The authors have no funding and conflicts of interest to declare. |
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| Contributed Indexing: | Keywords: case report; end-stage renal disease; intoxication; methotrexate |
| Substance Nomenclature: | YL5FZ2Y5U1 (Methotrexate) 0 (Antirheumatic Agents) |
| Entry Date(s): | Date Created: 20260822 Date Completed: 20260822 Latest Revision: 20260918 |
| Update Code: | 20260918 |
| PubMed Central ID: | PMC13502829 |
| DOI: | 10.1097/MD.0000000000050331 |
| PMID: | 42629702 |
| Βάση Δεδομένων: | MEDLINE |
| ISSN: | 1536-5964 |
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| DOI: | 10.1097/MD.0000000000050331 |