来氟米特与甲氨蝶呤联用致重度骨髓抑制伴慢性胆囊炎急性发作

Severe Bone Marrow Suppression Accompanying Acute Episode of Chronic Cholecystitis due to Leflunomide and Methotrexate Combination Therapy

1例66a类风湿关节炎女性患者在使用来氟米特(20 mg,qd,po)联合甲氨蝶呤(7.5 mg,qw,po)治疗1个月后出现口唇溃疡,血常规示三系明显降低。立即住院治疗。住院期间血象继续降低,达粒细胞缺乏症、严重血小板减少症及重度贫血水平;并出现腹痛,莫非氏征阳性。患者加用来氟米特与甲氨蝶呤治疗前血常规基本正常,但有慢性胆囊炎病史,因此考虑来氟米特与甲氨蝶呤合用致严重骨髓抑制伴机会性感染即慢性胆囊炎急性发作。予停用来氟米特与甲氨蝶呤。同时输注浓缩红细胞、机采血小板、使用重组人粒细胞集落刺激因子升白、抗感染等对症治疗。患者血细胞逐渐回升、胆囊炎得到控制,病情趋于稳定。

A 66-year-old female patient with rheumatoid arthritis developed mouth ulcers after receiving 1 month of leflunomide（ 20 mg,qd,po） and methotrexate（ 20 mg,qw,po） combination therapy. Routine blood test showed obvious decrease in blood counts. She was hospitalized immediately. During her hospitalization blood counts continued to decrease, reaching severe thrombocytopenia,agranulocytopenia,and severe anaemia,accompanied by abdominal pain with positive Murphy＇s sign. In view of the patient＇s relatively normal blood counts before the addition of leflunomide and methotrexate combination therapy,but with chronic cholecystitis,so severe bone marrow suppression accompanying opportunistic infection（ namely acute episode of chronic cholecystitis） associated with leflunomide and methotrexate combination therapy was considered. Leflunomide and methotrexate were stopped. Meanwhile other intensive supportive therapy was also implemented,including transfusion of red cells and platelets,use of recombinant human granulocyte colony-stimulating factor to increase the leukocyte count,anti-infection and so on. The patient＇s blood counts increased gradually,and cholecystitis was controlled with stable condition.