RESUMO
Abstract Methotrexate is an effective medication to control several diseases; however, it can be very toxic, being myelosuppression one of its main adverse effects, which increases in severity and frequency in patients with renal failure. We present the case of a 68-year-old man with chronic, end-stage renal disease associated with ANCA vasculitis, under treatment with peritoneal dialysis, who received the medication at a low dose, indicated by disease activity, which presented as a complication with severe pancytopenia with mucositis that improved with support measures and multiple-exchange peritoneal dialysis. We reviewed 20 cases published to date of pancytopenia associated with methotrexate in patients on dialysis and found high morbidity and mortality, which is why its use in this type of patient is not recommended. However, when this complication occurs, a therapeutic option could be the use of multiple-exchange peritoneal dialysis in addition to supportive therapy for drug-related toxicity, although it is recognized that studies are required to show the role of multiple-exchange peritoneal dialysis in the removal of this medication.
Resumo Apesar de sua toxicidade, o metotrexato é um medicamento eficaz no controle de várias doenças. A mielossupressão, um de seus principais efeitos adversos, aumenta em gravidade e frequência nos pacientes com insuficiência renal. Apresentamos o caso de um homem de 68 anos de idade com doença renal terminal relacionada à vasculite associada ao ANCA em diálise peritoneal, que recebeu a medicação em dose baixa em função da atividade da doença e que teve como complicação pancitopenia grave com mucosite, tratada com medidas de suporte e diálise peritoneal com múltiplas trocas. Revisamos 20 casos publicados até o presente momento sobre pancitopenia associada a metotrexato em pacientes em diálise. Foi identificada alta morbidade e mortalidade, razão pela qual seu uso nesse tipo de paciente não é recomendado. No entanto, quando esta complicação ocorre, uma opção terapêutica pode ser o uso de diálise peritoneal com múltiplas trocas, além da terapia de suporte para toxicidade medicamentosa. Maiores estudos são necessários para demonstrar o papel da diálise peritoneal com múltiplas trocas na remoção desse medicamento.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Vasculite/tratamento farmacológico , Metotrexato/efeitos adversos , Metotrexato/uso terapêutico , Diálise Peritoneal/métodos , Antagonistas do Ácido Fólico/efeitos adversos , Antagonistas do Ácido Fólico/uso terapêutico , Falência Renal Crônica/terapia , Pancitopenia/etiologia , Pancitopenia/terapia , Choque Séptico/etiologia , Choque Séptico/tratamento farmacológico , Metotrexato/sangue , Resultado do Tratamento , Mucosite/etiologia , Mucosite/tratamento farmacológico , Antagonistas do Ácido Fólico/sangue , Antibacterianos/uso terapêuticoRESUMO
Methotrexate is an effective medication to control several diseases; however, it can be very toxic, being myelosuppression one of its main adverse effects, which increases in severity and frequency in patients with renal failure. We present the case of a 68-year-old man with chronic, end-stage renal disease associated with ANCA vasculitis, under treatment with peritoneal dialysis, who received the medication at a low dose, indicated by disease activity, which presented as a complication with severe pancytopenia with mucositis that improved with support measures and multiple-exchange peritoneal dialysis. We reviewed 20 cases published to date of pancytopenia associated with methotrexate in patients on dialysis and found high morbidity and mortality, which is why its use in this type of patient is not recommended. However, when this complication occurs, a therapeutic option could be the use of multiple-exchange peritoneal dialysis in addition to supportive therapy for drug-related toxicity, although it is recognized that studies are required to show the role of multiple-exchange peritoneal dialysis in the removal of this medication.
Assuntos
Antagonistas do Ácido Fólico/efeitos adversos , Antagonistas do Ácido Fólico/uso terapêutico , Falência Renal Crônica/terapia , Metotrexato/efeitos adversos , Metotrexato/uso terapêutico , Diálise Peritoneal/métodos , Vasculite/tratamento farmacológico , Adulto , Idoso , Antibacterianos/uso terapêutico , Feminino , Antagonistas do Ácido Fólico/sangue , Humanos , Masculino , Metotrexato/sangue , Pessoa de Meia-Idade , Mucosite/tratamento farmacológico , Mucosite/etiologia , Pancitopenia/etiologia , Pancitopenia/terapia , Choque Séptico/tratamento farmacológico , Choque Séptico/etiologia , Resultado do TratamentoRESUMO
Methotrexate has been widely used for many years in the treatment of a variety of diseases. Acute pneumonitis and bone marrow suppression are very serious side effects in methotrexate treatment. A 48-year-old man with end-stage renal disease undergoing chronic hemodialysis developed combined acute pneumonitis and pancytopenia after a cumulative dose of 20 mg methotrexate for bullous pemphigoid. Continuous renal replacement therapy (CRRT) can efficiently decrease serum methotrexate concentration. A rapid improvement of clinical symptoms and resolution of pulmonary opacification were found after CRRT. Blood cell counts returned to normal after component blood transfusion and cytokine supportive therapy. Patients with impaired renal function are at high risk of methotrexate toxicity, and low-dose methotrexate should be prescribed with great caution.
Assuntos
Fármacos Dermatológicos/efeitos adversos , Doenças Pulmonares Intersticiais/induzido quimicamente , Metotrexato/efeitos adversos , Pancitopenia/induzido quimicamente , Penfigoide Bolhoso/tratamento farmacológico , Fármacos Dermatológicos/administração & dosagem , Humanos , Falência Renal Crônica/terapia , Doenças Pulmonares Intersticiais/terapia , Masculino , Metotrexato/administração & dosagem , Pessoa de Meia-Idade , Pancitopenia/terapia , Diálise Renal , Fatores de Risco , Resultado do TratamentoRESUMO
Methotrexate has been widely used for many years in the treatment of a variety of diseases. Acute pneumonitis and bone marrow suppression are very serious side effects in methotrexate treatment. A 48-year-old man with end-stage renal disease undergoing chronic hemodialysis developed combined acute pneumonitis and pancytopenia after a cumulative dose of 20 mg methotrexate for bullous pemphigoid. Continuous renal replacement therapy (CRRT) can effi ciently decrease serum methotrexate concentration. A rapid improvement of clinical symptoms and resolution of pulmonary opacifi cation were found after CRRT. Blood cell counts returned to normal after component blood transfusion and cytokine supportive therapy. Patients with impaired renal function are at high risk of methotrexate toxicity, and low-dose methotrexate should be prescribed with great caution.
.Assuntos
Humanos , Masculino , Pessoa de Meia-Idade , Fármacos Dermatológicos/efeitos adversos , Doenças Pulmonares Intersticiais/induzido quimicamente , Metotrexato/efeitos adversos , Pancitopenia/induzido quimicamente , Penfigoide Bolhoso/tratamento farmacológico , Fármacos Dermatológicos/administração & dosagem , Falência Renal Crônica/terapia , Doenças Pulmonares Intersticiais/terapia , Metotrexato/administração & dosagem , Pancitopenia/terapia , Diálise Renal , Fatores de Risco , Resultado do TratamentoRESUMO
Objetivo. Presentar el caso clínico de una paciente canina pancitopenica debido al uso indebido de estrógenos como método anticonceptivo. Materiales y métodos. Paciente canina de raza Poodle de 8 años, la cual fue llevada a consulta por presentar decaimiento, inapetencia, hemorragias petequiales e hipema. Resultado. Una vez realizada la anamnesis, el examen físico y los exámenes paraclínicos así como la evolución del cuadro clínico se demostró la intoxicación estrogénica exógena como diagnóstico definitivo. Conclusiones. El uso de estrógenos como método para la terminación de preñez en perras no está recomendado o considerado ético para muchos autores o asociaciones veterinarias por varias razones como: una dosis de estrógenos aparentemente efectiva no se ha establecido, por lo que su administración puede resultar en enfermedad uterina; dosis de estrógenos aparentemente seguras fueron determinadas como inseguras, y dosis aparentemente efectivas produjeron enfermedad uterina. La aplasia medular es un resultado común de la intoxicación estrogénica y esta puede conducir incluso a la muerte del paciente.
Assuntos
Dente Canino , Estrogênios , Pancitopenia , Prenhez , Trombocitopenia , Dente Canino/cirurgia , Dente Canino/fisiopatologia , Estrogênios/uso terapêutico , Pancitopenia/fisiopatologia , Pancitopenia/terapia , Prenhez/fisiologia , Trombocitopenia/enfermagem , Trombocitopenia/fisiopatologiaRESUMO
A 28 years old male on chronic hemodialysis for 40 months due to a IgA crescentic glomerulonephritis developed pancytopenia (hematocrit 16%, white blood cell count 3,800 mm3 and platelets 11,000 mm3. The bone marrow aspirate showed erythropoietic hyperplasia. Hemolytic anemia, folate or vitamin B12 deficiency and paroxysmal nocturnal hemoglobinuria were ruled out. Steroids were given with a transient elevation of red cells and platelets, which lasted only for some weeks. Afterwards, intravenous immunoglobulin was given without benefit. Two months after, a bone marrow biopsy and a bone marrow magnetic resonance imaging showed severe aplasia. Cyclosporine was started with a rapid increase in blood cells count. Eight months later, he received a renal transplant from a cadaveric donor. Immunosupression was achieved with cyclosporine, prednisone and mycofenolate mofetil. The patient required hemodialysis for the first three weeks and a mild acute cellular rejection was treated with methylprednisolone. At discharge, 6 weeks later, serum creatinine was 2.4 mg/dl and creatinine clearance 37.6 ml/min. During the first months after transplant, platelet count and hemoglobin decreased and a bone marrow biopsy showed only mild hypoplasia. Four months after renal transplant the hematocrit was 43%, white blood cell count 6,600 mm3 and platelets, 150,000 mm3 and did not change during the first year of follow up.
Assuntos
Anemia Aplástica/tratamento farmacológico , Ciclosporina/uso terapêutico , Imunossupressores/uso terapêutico , Diálise Renal , Adulto , Anemia Aplástica/etiologia , Glomerulonefrite por IGA/terapia , Humanos , Transplante de Rim , Masculino , Pancitopenia/terapia , Diálise Renal/efeitos adversosRESUMO
A 28 years old male on chronic hemodialysis for 40 months due to a IgA crescentic glomerulonephritis developed pancytopenia (hematocrit 16 percent, white blood cell count 3.800 mm3 and platelets 11.000 mm3. The bone marrow aspirate showed erythropoietic hyperplasia. Hemolytic anemia, folate or vitamin B12 deficiency and paroxysmal nocturnal hemoglobinuria were ruled out. Steroids were given with a transient elevation of red cells and platelets, which lasted only for some weeks. Afterwards, intravenous immunoglobulin was given without benefit. Two months after, a bone marrow biopsy and a bone marrow magnetic resonance imaging showed severe aplasia. Cyclosporine was started with a rapid increase in blood cells count. Eight months later, he received a renal transplant from a cadaveric donor. Immunosupression was achieved with cyclosporine, prednisone and mycofenolate mofetil. The patient required hemodialysis for the first three weeks and a mild acute cellular rejection was treated with methylprednisolone. At discharge, 6 weeks later, serum creatinine was 2.4 mg/dl and creatinine clearance 37.6 ml/min. During the first months after transplant, platelet count and hemoglobin decreased and a bone marrow biopsy showed only mild hypoplasia. Four months after renal transplant the hematocrit was 43 percent, white blood cell count 6.600 mm3 and platelets, 150.000 mm3 and did not change during the first year of follow up (Rev Méd Chile 2004; 132: 989-94).
Assuntos
Adulto , Humanos , Feminino , Imunossupressores/uso terapêutico , Anemia Aplástica/etiologia , Anemia Aplástica/tratamento farmacológico , Ciclosporina/uso terapêutico , Diálise Renal/efeitos adversos , Glomerulonefrite por IGA/terapia , Pancitopenia/terapia , Transplante de RimRESUMO
Nesta revisäo, säo discutidos os princípios do diagnóstico e tratamento das principais complicaçöes agudas, näo infecciosas, do transplante de células progenitoras hematopoéticas: pancitopenia, incompatibilidade no sistema ABO, mucosite, doença veno-oclusiva hepática, cistite hemorrágica, penumonite intersticial, cardiotoxicidade e doença do enxerto-contra-hospedeiro aguda. Oito casos clínicos, extraídos da casuística da nossa Unidade de TMO, säo descritos brevemente para ilustrar aspectos particulares das doenças discutidas no trabalho.
Assuntos
Humanos , Masculino , Feminino , Adulto , Adolescente , Transplante de Medula Óssea , Doença Enxerto-Hospedeiro/complicações , Células-Tronco Hematopoéticas , Doença Enxerto-Hospedeiro/fisiopatologia , Pancitopenia/diagnóstico , Pancitopenia/terapia , Transplante de Medula Óssea/mortalidadeRESUMO
Fanconi anemia is a congenital syndrome characterized by multiple specific physical anomalies, progressive marrow failure, and a predisposition to acute leukemia. We studied the toxicity and efficacy of daily subcutaneous administration of recombinant human granulocyte-macrophage colony-stimulating factor (GM-CSF) in patients with Fanconi anemia and pancytopenia. The toxicity of GM-CSF at the doses and schedule used was minimal. Six of seven patients entered had an increase in the neutrophil count of 7- to 25-fold, which was maintained during the course of study. Despite increases in the reticulocyte count, increases in hemoglobin concentration were rare. No improvement in platelet count was evident in any patient. No patient has evidence of leukemia after up to 19 months of continuous GM-CSF exposure, and all five surviving patients remain responsive to treatment. Although the optimal dose, schedule, and choice of cytokine for patients with marrow failure and Fanconi anemia are not established by this preliminary study, the data indicate that (1) GM-CSF may be able to palliate at least the neutropenia and potentially the neutropenic complications of the disease, (2) this effect can be sustained for more than 1 year, and (3) rapid evolution of acute leukemia is unlikely to be a frequent outcome of such treatment. The clinical impact of GM-CSF or other cytokines in patients with Fanconi anemia and pancytopenia remains to be established by further studies.