Severe apoptotic enteropathy caused by methotrexate treatment for rheumatoid arthritis.
The folic acid antagonist methotrexate is a cornerstone treatment of rheumatoid arthritis. Its use is limited chiefly by gastrointestinal toxicity, which is among the main reasons for methotrexate discontinuation. Here, we report the case of a 40-year-old man on chronic methotrexate therapy in whom life-threatening apoptotic enteropathy with watery diarrhea and hypovolemic shock developed after he was switched from the oral to the intramuscular route, with no change in dosage. Colonic biopsies suggested drug-induced colitis, showing a nonspecific, mildly inflammatory infiltrate of lymphocytes and plasma cells, dilated damaged crypts, and a marked increase in basal crypt apoptosis (>20 apoptotic bodies/100 crypts). Clinicians should be aware that methotrexate can cause life-threatening apoptotic enteropathy. Increased basal crypt apoptosis in colonic biopsies with more than 5 apoptotic bodies/100 crypts should routinely suggest drug-induced enteropathy.
Service de médecine interne et des maladies infectieuses et tropicales, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France. Electronic address: segolene-27@hotmail.fr.
Ségolène
S
Toquet
Service de médecine interne et des maladies infectieuses et tropicales, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France.
Yohan
Y
Nguyen
Service de rhumatologie, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France.
Adel
A
Sabbagh
Laboratoire de pharmacologie toxicologie, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France.
Zoubir
Z
Djerada
Laboratoire d'anatomo-pathologie, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France.
Camille
C
Boulagnon
Service de médecine interne et des maladies infectieuses et tropicales, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France.
Firouzé
F
Bani-Sadr
D000328:Adult; D018501:Antirheumatic Agents / Q000009:adverse effects* / Q000627:therapeutic use; D017209:Apoptosis; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001706:Biopsy; D003092:Colitis / Q000139:chemically induced* / Q000473:pathology; D003967:Diarrhea / Q000139:chemically induced; D006801:Humans; D007413:Intestinal Mucosa / Q000473:pathology; D008297:Male; D008727:Methotrexate / Q000009:adverse effects* / Q000627:therapeutic use
D018501:Antirheumatic Agents; D008727:Methotrexate
Apoptotic enteropathy; Chronic diarrhea; Drug-induced colitis; Methotrexate