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Joint Bone Spine
Volume 83, n° 2
pages 217-219 (mars 2016)
Doi : 10.1016/j.jbspin.2015.08.006
accepted : 28 May 2015
Severe apoptotic enteropathy caused by methotrexate treatment for rheumatoid arthritis

Ségolène Toquet a, , Yohan Nguyen a, Adel Sabbagh b, Zoubir Djerada c, Camille Boulagnon d, Firouzé Bani-Sadr a
a Service de médecine interne et des maladies infectieuses et tropicales, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France 
b Service de rhumatologie, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France 
c Laboratoire de pharmacologie toxicologie, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France 
d Laboratoire d’anatomo-pathologie, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France 

Corresponding author.

The folic acid antagonist methotrexate is a cornerstone treatment of rheumatoid arthritis. Its use is limited chiefly by gastrointestinal toxicity, which is among the main reasons for methotrexate discontinuation. Here, we report the case of a 40-year-old man on chronic methotrexate therapy in whom life-threatening apoptotic enteropathy with watery diarrhea and hypovolemic shock developed after he was switched from the oral to the intramuscular route, with no change in dosage. Colonic biopsies suggested drug-induced colitis, showing a nonspecific, mildly inflammatory infiltrate of lymphocytes and plasma cells, dilated damaged crypts, and a marked increase in basal crypt apoptosis (>20 apoptotic bodies/100 crypts). Clinicians should be aware that methotrexate can cause life-threatening apoptotic enteropathy. Increased basal crypt apoptosis in colonic biopsies with more than 5 apoptotic bodies/100 crypts should routinely suggest drug-induced enteropathy.

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Keywords : Apoptotic enteropathy, Methotrexate, Chronic diarrhea, Drug-induced colitis

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