Severe multiorgan toxicity after first dose of Capizzi methotrexate in a young adult patient with acute lymphocytic leukaemia

Abstract

Methotrexate is a versatile antineoplastic and immunosuppressive agent. We report a case of a young adult on the Cancer and Leukaemia Group B 10403 treatment protocol for B-cell acute lymphoblastic leukaemia. She has previously completed the induction and consolidation phases with good tolerance then started on Capizzi methotrexate during the interim maintenance phase. Few days after receiving one intermediate dose of methotrexate, she developed severe multiorgan toxicities including pancytopaenia and several dermatologic toxicities. The patient underwent extensive diagnostic workup, with all results negative, pointing eventually towards severe methotrexate toxicity. This case highlights the broad spectrum of toxicities that can occur even with low doses of methotrexate. Capizzi methotrexate therapy implies no leucovorin therapy, hence putting patients at risk for multiorgan toxicity. Our experience reinforces the importance of close monitoring for patients receiving methotrexate, regardless of dose, and the prompt administration of high-dose leucovorin once toxicity suspected.

Severe Methotrexate Toxicity Following a Capizzi Cycle in an Obese Adolescent With Acute Lymphoblastic Leukemia and Hepatic Steatosis

“…Caldito et. al 14 described a case of a 40-year-old female with obesity and hepatic steatosis who experienced similar severe multiorgan toxicity after C-MTX administration and had detectable methotrexate levels for more than 10 days after administration.…”

Dermatological toxicity of acute lymphoblastic leukemia treatment by protocol ALL IC-BFM 2002

“…Редко в подобных случаях развиваются печеночная, сердечно-сосудистая, дыхательная недостаточность, проявления кожной токсичности (синдром Стивенса-Джонсона и токсический эпидермальный некролиз). Лечебная тактика в подобных случаях включает проведение экстракорпоральных методов детоксикации, введение фолината кальция, иммуноглобулина и глюкокортикостероидов [7][8][9].…”

Reply to: “Severe Methotrexate Toxicity Following a Capizzi Cycle in an Obese Adolescent With Acute Lymphoblastic Leukemia and Hepatic Steatosis” Published January 2024

“…Subsequently, with precautions to ensure methotrexate clearance, she was able to complete her course of C-MTX. Another case report of a female patient treated for ALL who developed multiorgan failure with her first dose of C-MTX brings up the interesting question as to whether there is a gender predisposition for this toxicity, but overall, there were minimal reports of significant toxicity in patients with ALL receiving C-MTX 3,4 …”