Case Report
A 72 year male with history of rheumatoid arthritis with multiple joint
deformities was admitted with syncope and gastrointestinal bleeding. He
was taking methotrexate and hydroxychloroquine since last 7 years.
Perioral excoriation and petechial spots over palate were present. There
was no fever, lymph node enlargement or splenomegaly. Patient was given
3 doses of G-CSF and referred for hematology consult. Complete blood
count showed pancytopenia. Absolute neutrophil count was 0.06 x 109/L
and platelet count was 10 x 109/L. Red blood cells were normocytic
normochromic with low reticulocyte count. Direct antiglobulin test was
negative and LDH was normal.
Methotrexate was stopped. Bone marrow aspiration (Fig 1) and biopsy
showed hypercellular marrow with normoblastic erythroid maturation.
Myeloid precursors were increased in number with many promyelocyte with
prominent Golgi zone. Normal or reactive promyelocytes were
characterized by prominent paranuclear clear Golgi zones [1,2].
Megakaryocytes were adequate. No confluent blast aggregates or ALIP were
seen. A diagnosis of methotrexate induced bone marrow suppression was
made. Patient’s neutrophil counts and platelets showed dramatic recovery
the very next day of bone marrow examination and remained normal
thereafter.
Ethical approval : This article does not contain any studies
with human participants or animals performed by any of the authors.