Stevens-Johnson syndrome associated with methotrexate treatment for non-Hodgkin's lymphoma.

In recent years methotrexate has been used increasingly in combination chemo-therapeutic regimens for the treatment of aggressive non-Hodgkin's lymphoma. I Its principal toxic effects are bone marrow suppression, gastrointestinal mucositis, hepatitis, renal impairment, and erythematous rashes. The Stevens-Johnson syndrome has been reported previously in two children receiving high-dose methotrexate with leucovorin rescue for treatment of acute lymphoblastic leukaemia.2 The syndrome is characterized by severe erythema multiforme associated with orogenital mucosal ulceration, and may be complicated by severe systemic upset and hepatic, renal and neurological disturbances.3 We report a case of near-fatal Stevens-Johnson syndrome following intermediate dose methotrexate and leucovorin rescue in a patient receiving combination chemo-therapy for diffuse large cell non-Hodgkin's lymphoma. CASE REPORT. A 54-year-old man presented with cervical lymphadenopathy and an abdominal mass. Cervical lymph node biopsy demonstrated a diffuse large cell non-Hodgkin's lymphoma.4 Extensive involvement of mesenteric lymph nodes was demonstrated by CT scanning. He was treated with BCHOP-M chemo-therapy intravenously: bleomycin 10mg, cyclophosphamide 1-4 g, doxorubicin 76mg and vincristine 2mg on day 1; followed by oral prednisolone 40mg daily on days 1-5 and intravenous methotrexate 380mg on day 15, and leucovorin 30mg orally six-hourly for four doses on day 16. On days 22-24 he developed a fever, a generalised erythematous itchy rash, and severe mucosal ulceration of the orpharynx, glans penis, and anus. He had epidermal ulceration of the scrotum, perineum, and upper medial aspect of the thighs. On days 25-30 the rash became confluent over the whole body surface and began to blister over the trunk, palms and soles, gradually resolving over days 33-40.