Methotrexate is an essential drug effectively used in acute lymphoblastic leukemia. Doses above 500 mg/m2 are defined as high-dose methotrexate (HDMTX). Since HDMTX is known to cause serious morbidity, it is given with a standard rescue therapy to prevent toxicity. Besides myelosuppression and mucositis, other side effects of methotrexate are hepatotoxicity, erythema, desquamation, allergic reactions and neurotoxicity. Methotrexate is also associated with radiation recall and false photosensitivity. A 10-year-old girl with pre-B ALL underwent hematopoietic stem cell transplantation two times due to marrow and central nervous system (CNS) relapse. On the follow-up, 3 months later she had a bone marrow relapse. After remission obtained with high dose chemotherapy, maintenance treatment was given due to relapse/refractory disease. One year later she had isolated CNS relapse again and treated with intrathecal methotrexate, Ara-C and dexamethasone. The patient was started on relapse/refractory maintenance therapy, and 1 g/m2 methotrexate was given every 4 weeks. Immediately after intravenous methotrexate was given to the patient in the 13th week of her treatment, she complained of burning, pain and redness in the areas that had previously been desquamated due to sunburn. No additional treatment was given, except alkaline hydration and calcium folinate, when the findings were observed. The patient was started on antihistamine therapy. Methotrexate drug level reached 0.02 umol/L at the 54th hour, the i.v. hydration was stopped. The patient's red and itchy lesions healed within 2 days by benefiting from the antihistamine. She is being followed-up at our outpatient clinic weekly chemotherapy without any sign of relapse. This sunburn-like erythema after methotrexate administration might be associated with impaired mononuclear cell response in sun-exposed tissues. Our case stated that he went to the sea two weeks ago and that the bullae secondary to the sunburn that developed afterwards peeled off after they burst. In conclusion, patients with a history of recent generalized sunburn should have their methotrexate delayed to avoid this complication.
