Methotrexate Toxicity Masquerading as Systemic Lupus Erythematosus Flare: A Case Report
Published: November 1, 2025 | DOI: https://doi.org/10.7860/JCDR/2025/82340.22048
Siddharth Shah, Sunil Kumar, Yash Anand Chordia, Hem Menpara
1. Assistant Professor, Department of General Medicine, SBKS MI&RC, Sumandeep Vidhyapeeth (Deemed to be University), Vadodara, Gujarat, India.
2. Professor and Head, Department of General Medicine, SBKS MI&RC, Sumandeep Vidhyapeeth (Deemed to be University), Vadodara, Gujarat, India.
3. Resident, Department of General Medicine, SBKS MI&RC, Sumandeep Vidhyapeeth (Deemed to be University), Vadodara, Gujarat, India.
4. Resident, Department of General Medicine, SBKS MI&RC, Sumandeep Vidhyapeeth (Deemed to be University), Vadodara, Gujarat, India.
Correspondence
Dr. Yash Anand Chordia,
41, Shreenath Bungalows Opposite Yash Complex, Gotri, Vadodara-390021, Gujarat, India.
E-mail: ychordia99@gmail.com
A 36-year-old woman with Rheumatoid Arthritis (RA) and class V lupus nephritis presented with fever, dysphagia and oral mucosal bleeding. She had been prescribed Methotrexate (MTX) 15 mg weekly but used it irregularly-almost daily-for four months. On examination, she had oral ulcers, reduced mouth opening, diffuse hair thinning, and erythematous papules. Laboratory findings revealed severe pancytopenia, elevated liver enzymes, and an increased MTX level. Complement levels were normal and anti-dsDNA negative, making a Systemic Lupus Erythematosus (SLE) flare unlikely. The diagnosis of MTX toxicity was confirmed. She was managed with immediate MTX withdrawal, folinic acid rescue (15 mg i.v. every six hours for three days), blood transfusions, and supportive care. Her counts normalised, and mucositis resolved within two weeks. This case emphasises the diagnostic challenge in differentiating drug toxicity from disease flare in autoimmune patients and underscores the need for strict adherence to MTX monitoring guidelines.
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