www.ijbcp.com International Journal of Basic & Clinical Pharmacology | July-August 2012 | Vol 1 | Issue 1 Page 36 IJBCP International Journal of Basic & Clinical Pharmacology Print ISSN: 2319-2003 | Online ISSN: 2279-0780 Case Report Grade 4 oral mucositis and prolonged pancytopenia with high dose intravenous methotrexate in a patient of philadelphia positive acute lymphoblastic leukemia Vidisha M. Shah a, *, Dimple S. Mehta a INTRODUCTION Methotrexate has infrequently caused serious (sometimes fatal) side effects. Therefore, this medication should be used only to treat cancer and other severe diseases caused by an overactive immune system. 1 This medication is used to treat trophoblastic neoplasms, leukemia, breast cancer, psoriasis, osteosarcoma, mycosis fungoides, psoriatic arthritis, and a variety of solid tumors. 2 The most frequently reported adverse reactions include ulcerative stomatitis, leukopenia, nausea, and abdominal distress. Other frequently reported adverse effects are malaise, undue fatigue, chills and fever, dizziness and decreased resistance to infection. 3 One of the main secondary toxic side effects of antimitotic agents used to treat cancer patients is intestinal mucositis. This one is characterized by compromised digestive and absorptive functions, barrier integrity, and immune competence. 4 Clinical evidence from patients undergoing Methotrexate (MTX) therapy indicates that personal response to MTX is different. Some people display minor side effects, while others suffer from severe adverse effects that lead to the discontinuation of cancer therapy. Mucositis is the painful inflammation and ulceration of the mucous membranes lining the digestive tract, usually as an adverse effect of chemotherapy and radiotherapy treatment for cancer. 5 Mucositis usually appears along the entire gastrointestinal tract from mouth to anus and causes general debility. Mucositis of the intestine is characterized by increased crypt apoptosis and villus atrophy, leaving the mucosal tissue open to ulceration and infection. 6-8 For most cancer treatment, about 5-15% of patients get mucositis. Oral mucositis also represents a major nonhematologic complication of cytotoxic chemotherapy and radiotherapy associated with significant morbidity, pain, odynodysphagia, dysgeusia, and subsequent dehydration and malnutrition. 9 But severe (grade 3 or 4) mucositis due to MTX is a very rare finding. CASE REPORT We report a case of 25-year-old girl taking injectable methotrexate for Philadelphia positive Acute Lymphoblastic Leukemia (ALL). She was admitted to the hospital for her 1 st continuation therapy for ALL. She had already completed her induction phase. She was given high dose intravenous MTX (3 gm) diluted in normal saline over 20 hours infusion along with triple intrathecal ABSTRACT Antimetabolite drugs are rarely associated with grade 3 or 4 mucositis. However specific side effects such as bone marrow suppression, pancytopenia, hospitalization, high cost limit the use of intravenous methotrexate. Here we report a case of 25-year-old girl patient with Acute Lymphoblastic Leukemia (ALL) treated with 24 hour methotrexate in her continuous phase of chemotherapy. After 12 hours of completing the treatment she developed oral mucosal pain & she was not able to speak. After a week, her White Blood Cell (WBC) count was 600/cumm with fever and she could not speak and eat or drink. So she was hospitalized for few days till she can drink something. We report high grade mucositis with methotrexate. Hematologists should be aware of this possible side effect to undertake early intervention. Keywords: Methotrexate (MTX), Mucositis, Pancytopenia, ALL a Department of Pharmacology, C.U. Shah Medical College, Surendranagar 363001, India Received: 28 July 2012 Revised: 7 August 2012 Accepted: 9 August 2012 *Correspondence to: Dr. Vidisha M. Shah, Email: Vidisha_pharmac@yahoo.com doi: 10.5455/2319-2003.ijbcp000612