Acute methotrexate toxicity with severe oral ulcerations following inadvertent ingestion: a case report.
Ankitha Miriya Alias, Sreela Leela Srikantannair, Twinkle SivaPrasad et al.
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Case in brief
A 68-year-old woman with inflammatory arthritis developed oral erosions resembling erythema multiforme and blistering skin lesions over two weeks. Evaluation revealed that, because of a pharmacy dispensing error, she had taken methotrexate 7.5 mg instead of prescribed mirtazapine 7.5 mg for approximately one month. Investigations showed bicytopenia affecting leukocytes and erythrocytes, considered likely related to acute methotrexate toxicity. Methotrexate was stopped, and she received intravenous folinic acid and supportive treatments. The mucocutaneous lesions resolved, leukocyte counts improved, and hemoglobin remained stable at 11.0 g/dL before discharge.
What made this case unusual
The oral erosions resembled erythema multiforme, but were associated with inadvertent methotrexate ingestion caused by a dispensing error; blistering skin lesions and bicytopenia were also present.
Diagnostic / clinical pearl
Erythema multiforme–like oral lesions accompanied by skin blistering should prompt review of medication use and possible dispensing errors, particularly when blood counts are abnormal.