{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,17]],"date-time":"2026-09-17T06:05:05Z","timestamp":1789625105134,"version":"build-2803163510"},"reference-count":18,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"34","license":[{"start":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T00:00:00Z","timestamp":1787270400000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["lww.com","ovid.com"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2026,8,21]]},"abstract":"<jats:sec>\n                    <jats:title>Rationale:<\/jats:title>\n                    <jats:p>Methotrexate (MTX) is a first-line agent for rheumatoid arthritis, and impaired renal excretion drastically elevates the risk of fatal drug accumulation. End-stage renal disease (ESRD) patients face an extreme toxicity risk even under conventional low-dose MTX, yet related fatal cases remain underreported. This case highlights critical clinical warnings for rheumatologists and emergency physicians.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Patient concerns:<\/jats:title>\n                    <jats:p>A 71-year-old male with a 5-year history of rheumatoid arthritis and 1-year untreated chronic kidney disease stage 5 received weekly 10\u2009mg subcutaneous MTX for 3 consecutive weeks without folic acid supplementation or regular laboratory monitoring. One day after his latest injection, he developed persistent nausea, vomiting, extensive oral ulcers, a skin rash, and drowsiness.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Diagnoses:<\/jats:title>\n                    <jats:p>Severe MTX intoxication complicated by profound bone marrow suppression, septic shock, and multiple organ dysfunction syndrome. Persistently elevated serum MTX confirmed impaired renal drug clearance in ESRD.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Interventions:<\/jats:title>\n                    <jats:p>Immediate MTX discontinuation, leucovorin calcium rescue, continuous renal replacement therapy, broad-spectrum anti-infection treatment, blood product transfusion, and invasive mechanical ventilation for progressive circulatory and respiratory failure.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Outcomes:<\/jats:title>\n                    <jats:p>Serial serum MTX remained elevated 6 days after the final dose. Despite full intensive supportive care, the patient died of refractory septic shock and irreversible multiorgan failure.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Lessons:<\/jats:title>\n                    <jats:p>Conventional-dose MTX is contraindicated for ESRD patients. Mandatory pre-prescription renal function assessment, regular laboratory monitoring, and folate supplementation are essential to prevent life-threatening MTX toxicity in high-risk elderly populations.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1097\/md.0000000000050331","type":"journal-article","created":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T17:06:39Z","timestamp":1787331999000},"page":"e50331","update-policy":"https:\/\/doi.org\/10.1097\/lww.0000000000001000","source":"Crossref","is-referenced-by-count":0,"title":["Fatal intoxication caused by conventional-dose methotrexate in an elderly patient with end-stage renal disease"],"prefix":"10.1097","volume":"105","author":[{"given":"Qian","family":"He","sequence":"first","affiliation":[{"name":"Department of Emergency, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, People\u2019s Republic of 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life-threatening neutropenic enterocolitis in an elderly patient with rheumatoid arthritis: a case report and literature review.","volume":"38","author":"Lui","year":"2024","journal-title":"In Vivo"},{"key":"R14-20260917","doi-asserted-by":"crossref","first-page":"9608","DOI":"10.3390\/ijms26199608","article-title":"Alogliptin mitigates methotrexate-induced nephrotoxicity in a rat model: antagonizing oxidative stress, inflammation and apoptosis.","volume":"26","author":"Fahmy","year":"2025","journal-title":"Int J Mol Sci"},{"key":"R15-20260917","doi-asserted-by":"crossref","first-page":"579","DOI":"10.1186\/s13256-021-03111-x","article-title":"Methotrexate-induced toxidermia and pancytopenia in a patient with ectopic pregnancy: a case report.","volume":"15","author":"Refeno","year":"2021","journal-title":"J Med Case Rep"},{"key":"R16-20260917","doi-asserted-by":"crossref","first-page":"1495705","DOI":"10.3389\/fmed.2025.1495705","article-title":"High-flux hemodialysis as rescue therapy 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