# Fatal Neutropenia Sepsis Following Acute Methotrexate Toxicity

## TL;DR

A patient with chronic kidney disease and diabetes developed severe sepsis after a methotrexate dosing error, highlighting the need for careful medication management.

## Contribution

This case report highlights the risk of acute methotrexate toxicity in elderly patients with CKD and emphasizes the importance of proper dosing education.

## Key findings

- A dosing error led to acute methotrexate toxicity with neutropenic sepsis in a high-risk patient.
- Treatment with folinic acid, GM-CSF, and antibiotics led to recovery within 12 days.
- The case underscores the need for patient education to prevent life-threatening methotrexate complications.

## Abstract

Methotrexate (MTX) is widely used to manage autoimmune diseases such as rheumatoid arthritis, psoriasis, and eczema due to its anti-inflammatory and immunosuppressive properties. We present the case of a 69-year-old male individual with stage 3b chronic kidney disease (CKD) and diabetes mellitus, who developed acute MTX toxicity following a dosing error. The patient, prescribed MTX 7.5 mg weekly for chronic lower leg eczema, mistakenly took 5 mg every eight hours for four days. He presented with erythematous rashes, oral mucosal ulcerations, and pancytopenia, later diagnosed as neutropenic sepsis. Management included discontinuation of MTX, intravenous folinic acid, granulocyte-macrophage colony-stimulating factor (GM-CSF), and broad-spectrum antibiotics. By day 7, his blood counts and symptoms improved, and he was discharged on day 12. This case underscores the importance of patient education on proper MTX dosing to prevent life-threatening complications, particularly in high-risk populations such as the elderly and those with CKD.