Septic thrombophlebitis and severe methotrexate toxicity in a patient on peritoneal dialysis

Methotrexate (MTX) is commonly prescribed for inflammatory dermatologic conditions; however, dosing errors and impaired renal clearance can result in life-threatening toxicity. Patients with end-stage renal disease (ESRD) are at heightened risk due to reduced MTX elimination. We describe a case of severe MTX toxicity presenting with mucosal bleeding, pancytopenia, and hemodynamic instability following inadvertent daily dosing in a patient on peritoneal dialysis. During her hospital course, she developed septic thrombophlebitis associated with a hemodialysis catheter. Complex multidisciplinary care included rescue leucovorin, emergent hemodialysis, colony-stimulating growth factor, and intravenous antibiotics. She survived to discharge with a plan for continued hemodialysis, intravenous antibiotics, and urethroscopy for evaluation of genital ulcerations.