Hypoplastic Myelodysplastic Syndrome: Symptom of Methotrexate Toxicity in Rheumatoid Arthritis

Methotrexate is the conventional disease-modifying anti-rheumatic drug (DMARD) which is considered the drug of choice in the treatment of rheumatoid arthritis, but its prolonged use without monitoring leads to a number of complications involving different body systems. The toxic effects of long-term methotrexate (MTX) therapy mainly involve the liver, skin, gastrointestinal tract (GIT) and bone marrow. In the bone marrow, it mainly causes suppression of normal functionality, leading to the formation of abnormal blast cells and dysplasia. In this case report, we present a male patient with symptoms of hoarseness, fatigue and abnormal bleeding all of which can be affiliated with methotrexate-induced hypoplastic myelodysplasia. As pancytopenia can be a lethal complication of MTX toxicity, it is important to monitor the therapy and dosage of methotrexate so that in case of any unforeseen development of a complication vital steps may be taken to diagnose and treat it in time. Regarding our patient, after thorough history taking and undergoing extensive hematological workup, the diagnosis of MTX-induced hypoplastic myelodysplasia was made. His symptoms improved on withholding the drug methotrexate from his active regimen and adding folinic acid and colony-stimulating factors.