Cases reported "Arthritis, Rheumatoid"

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11/26. Low dose methotrexate therapy for rheumatoid arthritis complicated by pancytopenia and pneumocystis carinii pneumonia.

    In a patient with rheumatoid arthritis pancytopenia and pneumocystis carinii pneumonia occurred during low dose methotrexate therapy. This case emphasizes the potential development of opportunistic infections even with low dose methotrexate. pneumocystis carinii pneumonia resembles methotrexate induced pneumonitis. Therefore opportunistic infections should be considered before a definite diagnosis of methotrexate induced pneumonitis is made.
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12/26. Severe pancytopenia in a patient taking low dose methotrexate and probenecid.

    A patient with rheumatoid arthritis developed life-threatening pancytopenia resulting from low dose oral methotrexate (MTX) toxicity potentiated by probenecid. Clinically significant drug interactions are not frequently cited as risk factors for MTX hematologic toxicity. As low dose MTX is gaining increasing popularity in rheumatologic practice, these potentially serious interactions should be considered.
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13/26. methotrexate and trimethoprim-sulphamethoxazole--a potentially hazardous combination.

    A 74-year-old woman had been treated with methotrexate over 2 years for rheumatoid arthritis. She was admitted to the hospital because of non-healing leg ulcers. After being treated with trimethoprim-sulphamethoxazole for a urinary-tract infection, she developed severe pancytopenia, followed by pneumonia and septic shock. The patient died shortly after. Concomitant treatment with methotrexate and sulphonamides should be strongly discouraged.
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14/26. methotrexate-associated, early-onset pancytopenia in rheumatoid arthritis.

    A patient with rheumatoid arthritis presented with pancytopenia 3 weeks after initiation of low-dose methotrexate administered orally. She had minimal renal insufficiency and hypoalbuminemia prior to initiation of methotrexate therapy, and had received a nonsteroidal anti-inflammatory drug concurrently. Bone marrow recovery occurred within 3 weeks. patients receiving low-dose methotrexate therapy for rheumatoid arthritis require early monitoring for bone marrow injury, especially those who have risk factors for possible methotrexate toxicity.
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15/26. Acute myelogenous leukemia following immunosuppressive therapy for rheumatoid arthritis.

    A 51-year-old woman had acute myelogenous leukemia following log-term cyclophosphamide therapy for rheumatoid arthritis. After standard methods of management had failed, the rheumatoid arthritis showed considerable improvement in response to approximately 25 mg cyclophosphamide per day over a four-year period. At the end of this period, pancytopenia developed, and cyclophosphamide was discontinued. A bone-marrow aspirate showed nonspecific changes. However, four months later because of severe progressive pancytopenia, another bone-marrow examination was performed; it showed acute myelogenous leukemia. Therapy failed to induce a remission, and two months after diagnosis the patient died of aspergillosis. autopsy confirmed the presence of leukemic infiltration of bone marrow, lymph nodes, liver and spleen. These findings suggest a possible leukemogenic role of cyclophosphamide in this case and suggest that caution should be exercised in treating non-fatal diseases with antitumor drugs.
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16/26. pancytopenia related to azathioprine in rheumatoid arthritis.

    Two patients with rheumatoid arthritis developed pancytopenia during treatment with azathioprine 100 mg daily. In one patient this side effect occurred after three weeks, in the other after eight weeks of treatment. Rapid fall of platelets in one patient necessitated platelet transfusion. In the other patient additional treatment with allopurinol was probably responsible for the toxic effect. Haematological side effects of azathioprine are discussed.
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17/26. pancytopenia associated with low dose pulse methotrexate in the treatment of rheumatoid arthritis.

    Low dose pulse MTX was associated with the development of pancytopenia in six patients with RA. Two patients died. Factors implicated in the occurrence of this complication were renal impairment in five patients, medication errors by two patients, preexisting marrow injury from occult alcoholism in one patient, and an apparent idiosyncratic reaction to the drug in another. medication errors were associated with the use of five or more medications, and the unusual schedule of administration of low dose MTX may also have been contributory. From a consideration of the clinical pharmacokinetics of MTX, we suggest other factors that may predispose to the occurrence of marrow toxicity: the presence of hypoalbuminemia, interactions between MTX and other protein bound or weakly acidic drugs, and the repetitive dosing schedule of low dose MTX. Based on our experience, patients with impaired renal function (creatinine greater than or equal to 2.0 mg/dL) should not receive MTX. Renal function should be monitored regularly during treatment with MTX, and blood counts should be observed carefully if a new drug is added or substituted. A 5 mg test dose of MTX before initiating weekly therapy may identify patients with severe hypersensitivity to the drug. The potential risks of using MTX in a patient unwilling to accept blood products should be acknowledged and discussed with the patient. Furthermore, we recommend the use of leucovorin if pancytopenia occurs, even if low or undetectable serum levels of MTX are present.
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18/26. gold-induced bone marrow aplasia: successful treatment with antithymocyte globulin.

    A patient receiving gold treatment for rheumatoid arthritis developed sudden severe pancytopenia secondary to bone marrow aplasia. She required extensive hematological support but was unsuitable for bone marrow transplantation. Although early use of large doses of a chelating agent did not change the hematological parameters, subsequent use of antithymocyte globulin has been associated with substantial hematological improvement.
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19/26. arthritis and autoimmune pancytopenia.

    We report a patient who developed arthritis and pancytopenia without an underlying systemic disease. autoantibodies to all lines were demonstrated using an 125I-anti human IgG assay. Elution studies documented cross reactivity of an antibody between erythrocytes and platelets, a pathogenetic variation not previously reported.
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20/26. pancytopenia related eosinophilia in rheumatoid arthritis: a specific methotrexate phenomenon?

    methotrexate (MTX) induced pancytopenia has been reported in about 3% of patients with rheumatoid arthritis (RA) receiving low dose MTX. We describe 4 additional patients with RA (2M, 2F; mean age 65 yrs; mean duration of RA 9 yrs) who developed pancytopenia while receiving low dose MTX. risk factors identified for the development of pancytopenia in our patients included impaired renal function, hypoalbuminemia, advanced age, low folate level, concurrent use of multiple comedication, nonsteroidal antiinflammatory drugs, and cotrimoxazole). Remarkably, pancytopenia related eosinophilia was observed in blood and bone marrow after restoring the intracellular folate level by folinic acid. The range of eosinophils was 22-56% of the number of peripheral white blood cells (mean nadir 33%). The peak level of eosinophilic granulocytes was reached after a mean of 6 days in hospital (range 4-8), whereas the peak of neutrophils was reached after a mean of 11 days (range 9-13 days). The duration of the eosinophilic response was 11 days. As eosinophilia has not been observed in other drug induced pancytopenias in patients with RA this could be a specific MTX induced phenomenon.
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