Ahmad Zain, MBBS1, Amil Shah, DO1, Hammad Qadri, DO2, Sai Prasanna Lekkala, MBBS1, Osama Ijaz, MD3, Fatima Ashfaq, MBBS4, Syed Rafay H zaidi, MBBS1, Bryant Javier, DO1, Mustafa Nayeem, MD1, Muhammad Sohaib, MBBS1 1Parkview Medical Center, Pueblo, CO; 2United Health Services, Wilson Medical Center, Vestal, NY; 3SSM Health St. Mary's Hospital - St. Louis, Richmond Heights, MO; 4Nishtar Medical University, Multan, Punjab, Pakistan Introduction: Methotrexate is a widely used medication for inflammatory conditions like rheumatoid arthritis with reversible liver toxicity as its most common side effect. Although well tolerated, rarely it can cause irreversible liver fibrosis and cirrhosis. We describe a case of methotrexate-induced decompensated liver cirrhosis in a patient with 20 years of methotrexate use.
Case Description/
Methods: A 76-year-old female with a 20 year chronic history of rheumatoid arthritis managed with methotrexate presented with unresolving diarrhea, new onset bilateral lower extremity edema and mild abdominal distention. She was initially treated for suspected C. difficile infection with antibiotics & fidaxomicin. Initial imaging workup including bilateral lower extremity. Dopplers were negative for DVT, echo was unremarkable for any cardiac dysfunction. Her CT of the abdomen revealed cirrhosis with mild to moderate ascites. A Doppler ultrasound showed patent hepatic vasculature without evidence of portal vein thrombosis or other obstructive causes. Prior comparison of the abdomen pelvis a year ago did not show significant evidence of cirrhosis. Chronic liver disease workup, including viral hepatitis panels (A, B, C), autoimmune markers such as P-ANCA, C-ANCA, antimitochondrial antibodies, and anti-smooth muscle antibodies, iron studies, and ceruloplasmin levels, was negative. The patient was started on diuretics (spironolactone and furosemide), resulting in partial improvement of ascites. She later required large-volume paracentesis due to worsening ascites and was diagnosed with hepatorenal syndrome (HRS), necessitating specialized treatment. Methotrexate was discontinued during her hospitalization. Discussion: CLD with evidence clinically decompensated liver cirrhosis significantly decreases the five years survival rate and further deterioration. Although NAFLD and chronic alcohol use contribute to the major disease burden of cirrhosis, literature has reported uncommon cirrhosis associated with chronic use of methotrexate for rheumatoid arthritis. This case underscores the importance of regular monitoring in patients on long-term methotrexate therapy. Liver function tests and imaging should be performed periodically to detect early signs of hepatic dysfunction. Methotrexate cessation should be considered in patients with progressive liver damage to prevent irreversible fibrosis as they are at high risk due to dysregulation of innate immunity and increased pro-inflammatory cytokine production.
Figure: CT scan Abdomen showing liver cirrhosis and ascites
Disclosures: Ahmad Zain indicated no relevant financial relationships. Amil Shah indicated no relevant financial relationships. Hammad Qadri indicated no relevant financial relationships. Sai Prasanna Lekkala indicated no relevant financial relationships. Osama Ijaz indicated no relevant financial relationships. Fatima Ashfaq indicated no relevant financial relationships. Syed Rafay H zaidi indicated no relevant financial relationships. Bryant Javier indicated no relevant financial relationships. Mustafa Nayeem indicated no relevant financial relationships. Muhammad Sohaib indicated no relevant financial relationships.
Ahmad Zain, MBBS1, Amil Shah, DO1, Hammad Qadri, DO2, Sai Prasanna Lekkala, MBBS1, Osama Ijaz, MD3, Fatima Ashfaq, MBBS4, Syed Rafay H zaidi, MBBS1, Bryant Javier, DO1, Mustafa Nayeem, MD1, Muhammad Sohaib, MBBS1. P4019 - Methotrexate-Induced Decompensated Liver Cirrhosis: A Case Report, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
