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Aplastic anemia
4%
1/23
Hemolytic anemia
Megaloblastic anemia
9%
2/23
Microcytic anemia
Polycythemia
70%
16/23
Select Answer to see Preferred Response
This patient is suffering from fatigue and mucositis in the setting of a history of rheumatoid arthritis suggesting she is suffering from toxicity from methotrexate use. A megaloblastic anemia is common with methotrexate use. Folic acid deficiency leads to decreased DNA synthesis resulting in a megaloblastic anemia. Folic acid deficiency differs from vitamin B12 deficiency in 2 ways: 1) Neurologic symptoms (demyelination and subacute combined degeneration of the spinal cord) are seen with vitamin B12 deficiency but not with pure folate deficiency. 2) Folic acid deficiency is associated with a normal serum methylmalonic acid (MMA) and increased homocysteine; whereas, vitamin B12 deficiency leads to increases in both MMA and homocysteine. Methotrexate is commonly used as a disease-modifying agent in rheumatoid arthritis. As a dihydrofolate reductase inhibitor, it can cause a folate deficiency and a megaloblastic anemia. Other findings suggestive of methotrexate toxicity include mucositis and stomatitis. Figure A is a clinical image of glossitis/mucositis which can be seen as a toxicity of methotrexate. Incorrect Answers: Answer 1: Aplastic anemia is a possible complication of parvovirus B19 infection or with methotrexate use. It is a less common complication when compared to a megaloblastic anemia given the mechanism of methotrexate. Answer 2: Hemolytic anemia would present with jaundice, elevated LDH, and a low haptoglobin and can occur secondary to infections and certain drugs. It is a less likely diagnosis in this patient given her history of rheumatoid arthritis and absence of symptoms. Answer 4: Microcytic anemia would present with a decreased MCV and could occur secondary to iron deficiency or GI bleeding. A megaloblastic anemia is more common with methotrexate use. Answer 5: Polycythemia vera is a condition of increased cell counts of all 3 cell lines (platelets, white blood cells, and red blood cells). It would not be seen with methotrexate use. Bullet Summary: Megaloblastic anemia and mucositis are common complications seen with methotrexate use.
3.5
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