A Case of Diverticular Perforation in a Young Patient with Rheumatoid Arthritis on Methotrexate

Abstract

Background. Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate (MTX), are associated with gastrointestinal toxicity. MTX inhibits dihydrofolate reductase, but it is unclear if polymorphisms of the methylenetetrahydrofolate reductase (MTHFR) gene predict toxicity. Case. We describe a 33-year-old male with polyarticular rheumatoid arthritis who developed sigmoid diverticular perforation while receiving methotrexate, folic acid, prednisone, and naproxen. He tested heterozygous for the C677T allele MTHFR gene. Discussion. Rheumatoid arthritis and its treatments are associated with increased risk of gastrointestinal disease. In one study, perforation was highest among individuals with concomitant exposure to NSAIDs, nonbiologic DMARDs, and glucocorticoids. Multiple mutations of the MTHFR gene have been identified, but their association with MTX toxicity is unclear. This case adds to a growing body of literature that could help inform the treatment of others in the future.

Silent Sigmoid Colon Diverticular Perforation: A Case Report

“…A recent hypothesis regarding the association between disease-modifying antirheumatic drugs (DMARDs) and spontaneous diverticular perforation has been proposed in the literature, but a definitive association has not been established yet. A given example of this association is a case of a rheumatoid arthritis patient on methotrexate who had a spontaneous diverticular perforation [ 6 ].…”

Recurrent Asymptomatic Sigmoid Diverticular Perforation in a Patient with Pemphigus Vulgaris on Immunosuppressive Therapy: A Case Report

“…To our knowledge, there have been no previously reported cases with a similar presentation. A previously published report of a symptomatic case in a patient with rheumatoid arthritis attributed spontaneous diverticular perforation to the use of the disease-modifying antirheumatic drug (DMARD), methotrexate [11]. However, there have been no subsequent studies that have confirmed an association between the use of DMARDs and spontaneous diverticular perforation.…”