MED12 Cryptococcosis as a complication of methotrexate therapy. (Medicine).

MED12 CRYPTOCOCCOSIS AS A COMPLICATION OF METHOTREXATE THERAPY. Jaroslaw P. Opiela, MD. Medical Park Hospital, Hope, Ark.

I am reporting a case of the fatal opportunistic infection with cryptococcosis in a patient receiving methotrexate therapy. A 69-year-old white woman with a medical history of methotrexate-controlled rheumatoid arthritis and diabetes mellitus had progressive nausea and vomiting for 2 weeks. She also had nonhealing bilateral foot ulcers and abdominal rash. She had mild epigastric tenderness, bilateral foot ulcers, and erythematous rash under the abdominal skin folds. Her initial evaluation revealed leukopenia, eosinophilia, normocytic and normochromic anemia, elevated kidney indices, and hypoalbuminemia. Chest x-ray revealed bilateral diffuse alveolar interstitial infiltrates. The patient's methotrexate toxicity was treated with leucovorin and urine alkalization. G.-CSF was added to facilitate bone marrow recovery, but subsequently the patient became neutropenic. Sputum cultures revealed Enterococcus faecalis sensitive to levofloxacin, which was part of the initial broad spectrum antibiotic coverage. The patie nt's clinical condition and neutropenia gradually improved until the seventh day of hospitalization when she had acute respiratory failure. Chest x-ray changed pattern to nodular and bronchoscopy was nondiagnostic. Despite empirical antibiotic coverage of opportunistic pathogens, the patient became septic. Shortly before her death, cryptococcal antigen in serum returned positive. This clinical variant represents severe bone marrow suppression and secondary cryptococcosis, which is a rare complication of methotrexate treatment and is frequently fatal.