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Nelarabine-induced myelopathy in patients undergoing allogeneic hematopoietic cell transplantation: a report of three cases. Int J Hematol 2023; 117:933-940. [PMID: 36705847 DOI: 10.1007/s12185-023-03539-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/11/2023] [Accepted: 01/11/2023] [Indexed: 01/28/2023]
Abstract
Nelarabine is an effective treatment for T-cell acute lymphoblastic leukemia/lymphoma. Myelopathy is a rare but serious adverse event associated with this drug. Three patients who received nelarabine at the National Cancer Center Hospital from December 2014 to March 2021 developed myelopathy 20 days before, 12 days after, and 29 days after allogeneic hematopoietic cell transplantation (allo-HCT), respectively. Magnetic resonance imaging showed that two of the patients had lesions in the dorsal column or medulla oblongata, and one had no abnormalities in the head or spine. Despite treatment with intravenous immunoglobulin and methylprednisolone, all patients became unable to walk. One patient died on day 101 after allo-HCT due to progressive neurotoxicity. The other two patients showed spontaneous improvement in neurological symptoms, but one died of mucormycosis on day 476. Autopsy revealed spongiosis in the posterior funiculus in both patients who died, and also in the medulla oblongata in one patient. In the surviving patient, positron emission tomography on day 84 showed abnormal accumulation, suggesting continued inflammation. These cases demonstrated pathophysiological features of nelarabine-induced myelopathy and indicate that allo-HCT may worsen the condition. It is necessary to elucidate the underlying mechanism and establish diagnostic methods and therapies.
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Serrallach BL, Schafer ES, Kralik SK, Tran BH, Huisman TAGM, Wright JN, Morgan LA, Desai NK. Imaging Findings in Children Presenting with CNS Nelarabine Toxicity. AJNR Am J Neuroradiol 2022; 43:1802-1809. [PMID: 36328408 DOI: 10.3174/ajnr.a7692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
Nelarabine is a nucleoside analog critical for the treatment of patients with T-cell acute lymphoblastic leukemia/lymphoma. However, clinical peripheral and central neurologic adverse events associated with nelarabine administration have been reported. Neuroimaging of brain neurotoxicity has only been described in very few reports in pediatric patients so far. Six children with diagnosed T-cell acute lymphoblastic leukemia who clinically experienced possible, probable, or definite nelarabine-induced toxicity and underwent spine and/or brain MR imaging were reviewed. Neuroimaging findings showed a mixture of patterns including features of acute toxic leukoencephalopathy (seen in 6 cases), posterior reversible encephalopathy syndrome (2 cases), involvement of deep gray structures (1 case) and brainstem (2 cases), cranial and spinal neuropathy (2 cases each), and myelopathy (2 cases). Even though neuroimaging findings are nonspecific, the goal of this article was to alert the pediatric neuroradiologists, radiologists, and clinicians about the possibility of nelarabine-induced neurotoxicity and its broad neuroimaging spectrum.
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Affiliation(s)
- B L Serrallach
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | - E S Schafer
- Department of Pediatrics (E.S.S.), Section of Hematology-Oncology, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - S K Kralik
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | - B H Tran
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | - T A G M Huisman
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
| | | | - L A Morgan
- Neurology (L.A.M.), Division of Child Neurology, Seattle Children's Hospital, Seattle, Washington
| | - N K Desai
- From the Edward B. Singleton Department of Radiology (B.L.S., S.K.K., B.H.T., T.A.G.M.H., N.K.D.)
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Nakamura T, Nishi M, Rikitake M, Koga D, Eto J, Tajima D, Toda S, Matsuo M. A case of subacute combined degeneration of the spinal cord due to folic acid and copper deficiency. Brain Dev 2019; 41:111-115. [PMID: 30104084 DOI: 10.1016/j.braindev.2018.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 07/02/2018] [Accepted: 07/11/2018] [Indexed: 11/27/2022]
Abstract
Subacute combined degeneration of the spinal cord (SACD) is a rare neurologic disorder manifesting progressive symptoms of paresthesia and spastic paralysis. Herein we present an autopsy case of SACD caused by folic acid and copper deficiency. A 16-year-old male presented with gradually worsening unsteady gait, and bladder and rectal dysfunction. He had a medical history of T-cell acute lymphoblastic leukemia (T-ALL), diagnosed 1.5 years previously. The patient had undergone chemotherapy, including methotrexate, as well as allogeneic bone mallow transplantation. Laboratory tests revealed normal vitamin B12 and methylmalonic acid concentration, but reduced serum copper, ceruloplasmin and folic acid concentrations. Magnetic resonance imaging revealed symmetrical T2 signal hyperintensities in the posterior and lateral spinal cord. The patient was treated with oral copper, oral folate, and intravenous vitamin B12. A month after this treatment, the patient's symptoms were unchanged, and 2 months later he died of acute adrenal insufficiency. The pathological findings of the spinal cord were compatible with SACD. Because SACD is usually reversible with early treatment, it should be suspected in high-risk patients undergoing chemotherapy or those who are malnourished with characteristic symptoms of SACD, even in young patients.
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Affiliation(s)
- Takuji Nakamura
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan; Department of Pediatrics, National Hospital Organization Ureshino Medical Center, 2436 Ureshino, Saga 843-0393, Japan.
| | - Masanori Nishi
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Mihoko Rikitake
- Department of Pathology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Daisuke Koga
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Junya Eto
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan; Department of Pediatrics, Saga-ken Medical Center Koseikan, 400 Nakabaru, Kase-machi, Saga 840-8571, Japan
| | - Daisuke Tajima
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan; Department of Pediatrics, Karatsu Red Cross Hospital, 2430 Watada, Karatsu, Saga 847-8588, Japan
| | - Shuji Toda
- Department of Pathology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Muneaki Matsuo
- Department of Pediatrics, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
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