Methotrexate induced lung injury in a patient with primary CNS lymphoma: a case report

Evaluation of the Protective Effect of Citral, Silymarin, and Thymoquinone on Methotrexate-Induced Lung Injury in Rats

Objectives

Several studies have reported that methotrexate is an anti-cancer and immunosuppressive drug leading to lung injury. Therefore, the present study aimed to investigate the protective effects of silymarin, citral, and thymoquinone on methotrexate-induced pulmonary toxicity.

Methods

Forty-eight rats were divided into six groups, including healthy, Methotrexate, and drug carrier control groups and silymarin, citral, and thymoquinone treatment groups. At the end of the experiment, the studied rats were anesthetized and sacrificed by CO₂. Lung tissue samples were isolated to measure the antioxidant activity and histopathological evaluation.

Results

In the thymoquinone treatment group, the concentration of total antioxidant capacity and Malondialdehyde increased and decreased significantly, respectively, compared to the methotrexate group. The histopathological evaluation of the lung of the methotrexate group showed hemorrhage and congestion, the nodule-like accumulation of mononuclear inflammatory lymphocytes around the blood vessel, a small number of neutrophils around the blood vessel, and the inflammatory cells around the small vessels. However, no significant pathological alterations were observed in the treatment groups, especially the thymoquinone treatment group.

Conclusion

Thymoquinone has the greatest protective effect on methotrexate-induced lung injury, probably due to its antioxidant effect.

Methotrexate pneumonitis in a patient with gestational trophoblastic neoplasia

Methotrexate, an immunomodulatory agent used for a wide variety of indications, can cause pulmonary toxicity in the form of pneumonitis, organising pneumonia, pulmonary fibrosis, pleural effusion, pulmonary infections or lymphoproliferative disease. We report a case of methotrexate pneumonitis in a patient with gestational trophoblastic neoplasia. The diagnosis of methotrexate pneumonitis is challenging, as the signs and symptoms can be caused by intercurrent infection, concomitant medications or an underlying disease condition. A high index of suspicion is required for diagnosis. Management consists of drug discontinuation and steroids in patients with respiratory failure.

Successful Use of High Dose Methotrexate in Treatment of Primary CNS Lymphoma Patients Without Access to Serum Methotrexate Levels Monitoring: Challenges and Outcome

AIMS AND OBJECTIVES

High dose methotrexate (HDMTx) based chemotherapy forms the backbone of therapy for patients with Primary Central Nervous system Lymphoma (PCNSL). However, delivering HDMTx in resource constrained settings, especially without therapeutic drug monitoring, is difficult. We share our experience of treatment of patients with PCNSL at our center over a 10-year period with local adaptations made to deliver HDMTx.

MATERIALS AND METHODS

We retrospectively analysed the case records of patients diagnosed with a PCNSL over the course of 10 years from 2010 to 2020.

RESULTS

Fifty-five patients received therapy for newly diagnosed PCNSL. Thirty-six patients received Modified De-Angelis protocol ± Rituximab with curative intent. Fourteen of these patients were unable to complete the protocol with the most common cause being development of methotrexate toxicity. Patients unable to complete the designated 5 cycles of HDMTx had a poorer PS and higher probability of having a high IELSG score at baseline. Nineteen patients were given non HDMTx based therapy either due to advanced age or poor performance status. Twenty-nine patients (52.7%) were able to achieve a complete response. The most common cause of mortality was relapse/progressive disease. The Median EFS and OS of the cohort was 29 months and 40 months respectively.

CONCLUSION

All attempts should be made to have therapeutic drug level monitoring for administration of HDMTX based therapy for the patients with PCNSL, more so in patients who have poor performance status and a high IELSG score. If it is imperative to give HDMTx without access to TDM facility then a possible risk of higher toxicity should be explained to all patients, beforehand.

Connective Tissue Disease Related Interstitial Lung Disease

Patients with connective tissue diseases may have pulmonary involvement, including interstitial lung disease. Various patterns of interstitial lung disease have been classically described in certain connective tissue diseases. It is now recognized that there is significant overlap between patterns of interstitial lung disease observed in the various connective tissue diseases. Differentiating idiopathic from connective tissue disease-related interstitial lung disease is challenging but of clinical importance. New concepts in the diagnosis of connective tissue disease related interstitial lung disease may prove useful in making the diagnosis.

Bone marrow and adipose mesenchymal stem cells attenuate cardiac fibrosis induced by methotrexate in rats

Mesenchymal stem cells (MSCs) are an ideal adult stem cell with capacity for self-renewal and differentiation with an extensive tissue distribution. The present study evaluates the therapeutic effects of bone marrow mesenchymal stem cells (BM-MSCs) or adipose-derived mesenchymal stem cells (AD-MSCs) against the development of methotrexate (MTX)-induced cardiac fibrosis versus dexamethasone (DEX). Rats were allocated into five groups; group 1, received normal saline orally; group 2, received MTX (14 mg/kg/week for 2 weeks); groups 3 and 4, treated once with 2 × 10⁶ cells of MTX + BM-MSCs and MTX + AD-MSCs, respectively; and group 5, MTX + DEX (0.5 mg/kg, for 7 days, P.O.). MTX induced cardiac fibrosis as marked changes in oxidative biomarkers and elevation of triglyceride, cholesterol, aspartate aminotransferase, gamma-glutamyl transferase, creatine kinase, and caspase-3, as well as deposited collagen. These injurious effects were antagonized after treatment with MSCs. So, MSCs possessed antioxidant, antiapoptotic, as well antifibrotic effects, which will perhaps initiate them as notable prospective for the treatment of cardiac fibrosis.