Acute mucocutaneous methotrexate toxicity with marked tissue eosinophilia

Abstract

Methotrexate toxicity in mucocutaneous areas is usually not associated with tissue eosinophilia. We describe a case of acute methotrexate-induced mucocutaneous erosions with interface dermatitis and eosinophils. A 76-year-old African-American woman with a history of bullous pemphigoid on methotrexate therapy presented with lower extremity cellulitis, developing oral and cutaneous erosions during hospitalization after daily dosage of methotrexate. Shallow circular cutaneous erosions were found on chest, abdomen and limbs. Laboratory results showed pancytopaenia and elevated liver function tests. Skin biopsy revealed irregular acanthotic epidermis with interface dermatitis, individual dyskeratotic cells and superficial perivascular lymphocytic infiltrate with numerous eosinophils. Methotrexate was stopped and leucovorin was administered, leading to improvement. The histopathological changes in acute mucocutaneous toxicity range from pauci-inflammatory erosions with dyskeratotic keratinocytes to interface dermatitis and infrequently seen eosinophils. This case exemplifies that interface dermatitis with a marked eosinophilic infiltrate can be found in the setting of acute mucocutaneous methotrexate toxicity.

Methotrexate-induced cutaneous ulceration and necrosis in chronic atopic dermatitis

“… 2 There are only 8 reported cases in nonpsoriatic patients with an underlying primary dermatologic disease, either bullous pemphigoid or mycosis fungoides ( Table I ). 2 , 5 , 6 , 7 , 8 To our knowledge, this is the first reported case of methotrexate-induced cutaneous ulceration and necrosis in atopic dermatitis. The latter is especially important because methotrexate is frequently used to treat pediatric and adult atopic dermatitis.…”

Hypereosinophilia as a Rare Side Effect of Methotrexate in a Patient with Erythrodermic Psoriasis: The First Case Report

“…Isolated eosinophilia during MTX treatment is extremely rare, with only three reported cases; two with juvenile idiopathic arthritis and one with rheumatoid arthritis [4]. Based on the compatible of interface dermatitis with a remarked eosinophilic infiltration can be found in the setting of acute mucocutaneous MTX toxicity [3,5], the diagnosis of hypereosinophilia as a drug adverse reaction was also supported by the dramatic improvement of symptoms as well as decreased number of eosinophils after withdrawal of MTX. To the best of our knowledge, our patient was the first case that showed nonspecific clinical manifestations related to a hypersensitive drug reaction including an intense pruritus, severe fatigue and flare of psoriatic lesions that may challenge in early recognition [6].…”

High-Dose Methotrexate-Induced Dermatological Eruption: A Rare Manifestation of Chemotoxicity

“…Pulse LD-MTX therapy given weekly without leucovorin rescue for psoriasis and rheumatoid arthritis commonly causes dermatological eruptions at a lower threshold than HD-MTX (0.2 vs 1 mM/L). 1 Perifolliculitis, photosensitivity, erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis occur due to immunologic mechanisms from drug presentation by keratinocytes to cytotoxic T lymphocytes. 2 3 Palmoplantar erythema with bullous lesions result due to concentration of this drug in eccrine glands.…”