Nico Gagelmann: Recognizing Methotrexate Toxicity – A Case of Severe Anemia in a patient with Rheumatoid Arthritis
Nico Gagelmann, Young National Society Ambassador at European Hematology Association (EHA), shared a post on X:
“Patient with rheumatoid arthritis presents to ER with severe anemia. Diagnosis?”
“Methotrexate toxicity -primarily manifests as bone marrow suppression and affects multiple blood cell lineages
- Anemia, leukopenia (particularly neutropenia), thrombocytopenia
- Dose-dependent toxicity
- More pronounced in patients with renal impairment or prolonged use such as this case of rheumatoid arthritis
Features:
- Pancytopenia: Reduction in all three blood cell lines.
- Neutropenia: Predisposes patients to severe infections.
- Thrombocytopenia: Increases the risk of bleeding. Anemia: often first feature, fatigue and general weakness.
Histopathology:
- Bone Marrow: Shows hypocellularity or aplasia due to the toxic effects on proliferating hematopoietic cells. Megakaryocytes: May be markedly reduced, leading to low platelet production.
- Granulopoiesis: Exhibit maturation arrest or reduced precursor numbers. Myeloid and erythroid: May show dysplastic changes, such as abnormal nuclear shapes, reflecting impaired maturation due to folate deficiency caused by MTX inhibition of dihydrofolate reductase. Lymphoid depletion: In some cases, reflecting the impact on rapidly dividing cells.
Nico Gagelmann is a physician and scientist who co-founded and co-chairs the European Society for Blood and Marrow Transplantation (EBMT) Trainee Committee, and he also serves as the chair of the EBMT subcommittee focused on CAR-T cell therapies for plasma cell disorders. His work is particularly impactful in the realm of CAR-T treatments for multiple myeloma, where he has contributed to advancing research and clinical approaches.
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