Pancreatitis with ALL patient

During the induction phase of ALL tretment on my 4 yr old daughter she developed acute pancreatitis from the use of Peg Aspariginase. It was misdiagnosed and the chemo treatment continued. We are in the induction phase and my daughter receives a 4hr drip of Methotrexate and an intrathecal injection as well. On the first MTX treatment my daughter devolped severe pain in the abdomen and when we had an ultrasound a pseudocyst was found measuring in cms 7x9x12. The surgeons dealt with this and drained the cyst and we have been monitoring this. The oncology team could not find any evidence of MTX causing any pancreatic problems. My daughter went for the next treatment four weeks later and after the MTX levels decreased she deveolped pancreatitis again with Amylase levels at 276 and Lipase at 198. We are changing the MTX drip to a 24 HR drip. During the MTX treatment she is rescued with the use of Leucovorin. My daughter also gets MP-6 each day as a maintenance drug. We are scheduled for a MRCP in two days to see the damage. She is too small for a ERCP. Do you have any ideas or have you heard of any other cases like this? Thank You.

[Kevin Pho, MD]

Here are the major GI side effects of methotrexate from a drug handbook.  I was not able to find a connection between this medication and pancreatitis:

"Gastrointestinal: Ulcerative stomatitis, glossitis, gingivitis, nausea, vomiting, diarrhea, anorexia, intestinal perforation, mucositis (dose dependent; appears in 3-7 days after therapy, resolving within 2 weeks)"

I looked up 6-MP and leucovorin as well and was not able to associate a connection with pancreatitis.

However, it is wholly possible that any medication can cause pancreatitis.  For example, dideoxyinosine, DDI (used for treating AIDS), 6-mercaptopurine, 6-MP (an immunosuppressant drug), and angiotensin-converting enzyme (ACE) inhibitors (used for treating high blood pressure).  

Also note that up to 1/3 of cases of pancreatitis do not have a clear cause.  The MRCP would seem like a reasonable next step to determine the etiology.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

Bibliography:
Kremer.  Major side effects of methotrexate.  UptoDate, 2004.
Chari.  Patient information: Acute pancreatitis.  UptoDate, 2004.