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Panicker VV, Radhakrishnan SE, Kuruttukulam GV, Bose JA, Favas TT. Methotrexate-Induced Leukoencephalopathy as a Clinical and Radiological Mimicker of Acute Ischemic Stroke Leading to Thrombolysis. Cureus 2024; 16:e51542. [PMID: 38314004 PMCID: PMC10834224 DOI: 10.7759/cureus.51542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/02/2024] [Indexed: 02/06/2024] Open
Abstract
Methotrexate (MTX) is used to treat acute lymphoblastic leukemia (ALL). It acts by inhibiting cell proliferation through its role as a folate antagonist. Despite its positive impact on patients' survival, high-dose MTX therapy carries risks, notably neurotoxic side effects such as subacute leukoencephalopathy that can mimic stroke symptoms. Recognizing and managing MTX-induced neurotoxicity promptly is crucial. We present a case involving an 18-year-old male diagnosed with B-cell ALL who presented with symptoms of MTX-induced leukoencephalopathy, initially resembling a stroke. The initial neurological examination and imaging results closely resembled those of a stroke, prompting the activation of a stroke code. Due to uncertainty regarding whether it was an acute ischemic stroke, the patient underwent thrombolysis. However, a thorough assessment of the medical history, treatment timeline, and imaging features, combined with the absence of large vessel occlusions on the magnetic resonance angiogram, led to the diagnosis of MTX-induced leukoencephalopathy. Our patient demonstrated complete clinical and radiological improvement within the following ten days. This underscores the significance of thorough history-taking, especially regarding drug history, to distinguish stroke mimics and contemplate MTX-induced leukoencephalopathy as a potential factor in ALL patients receiving MTX treatment. Recognizing these cases is essential to preventing unnecessary thrombolysis.
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Affiliation(s)
| | | | | | | | - T T Favas
- Neurology, Rajagiri Hospital, Kochi, IND
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Fujisawa H, Mitsui Y, Narukawa K, Shirasugi Y, Komaki S, Hao A, Matsumoto H, Takahashi T. Methotrexate-induced Subacute Encephalopathy That Showed No Abnormalities on Magnetic Resonance Imaging Soon after Symptom Appearance. Intern Med 2023; 62:2249-2252. [PMID: 36476551 PMCID: PMC10465289 DOI: 10.2169/internalmedicine.0855-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/27/2022] [Indexed: 12/12/2022] Open
Abstract
A 21-year-old woman was diagnosed with acute lymphoblastic leukemia. After the administration of intrathecal methotrexate (MTX), the patient experienced dysarthria and paralysis for one hour. Magnetic resonance imaging (MRI) performed one hour from the onset and just before symptoms disappeared revealed no abnormalities. The next day, the symptoms appeared again, and diffusion-weighed MRI revealed a high-intensity area in the left frontal lobe. The patient was diagnosed with MTX-induced encephalopathy. This case suggested that MRI performed as soon as symptoms appear might show normal findings in MTX-induced encephalopathy.
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Affiliation(s)
| | - Yurika Mitsui
- Division of Hematology, Mitsui Memorial Hospital, Japan
| | | | | | - Shogo Komaki
- Division of Neurology, Mitsui Memorial Hospital, Japan
| | - Akihito Hao
- Division of Neurology, Mitsui Memorial Hospital, Japan
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Peled Y, Levin D, Shiran S, Manisterski M, Shukrun R, Elhasid R. Prevalence and management of methotrexate-induced neurotoxicity in pediatric patients with osteosarcoma: a single-center experience. Int J Clin Oncol 2022; 27:1372-1378. [PMID: 35639227 DOI: 10.1007/s10147-022-02184-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/27/2022] [Indexed: 11/05/2022]
Abstract
AIMS To determine the incidence, clinical presentation, and outcome of methotrexate (MTX) associated neurotoxicity in pediatric patients treated for osteosarcoma, with the aim of identifying possible risk factors and suggesting recommended treatment for these sequelae. MATERIALS AND METHODS All medical files of patients treated for osteosarcoma in a single pediatric haemato-oncology center between November 2011 and August 2021 were retrospectively reviewed. All patients were treated according to the EURAMOS AOST0331 protocol, using cisplatin, doxorubicin, and high-dose MTX at a dose of 12 g/m2 over 4 h. RESULTS Seventy-eight patients with osteosarcoma were identified (age range 5 to 23 years, 42 males). Seven patients (9%) sustained neurotoxicity following treatment with high-dose MTX. Manifestations of neurotoxicity included among others, generalized seizures, confusion, encephalopathy, dysarthria, and choreiform movements. All but one episode occurred following two sequential cycles of high-dose MTX. All 7 had subacute toxicity, 5-10 days following MTX administration, and 1 had both acute and subacute toxicity. Brain MRI was performed for all patients and demonstrated typical MRI changes attributed to MTX neurotoxicity in 4 of them. Two patients received aminophylline; one patient received dextromethorphan. Patients with normal MRI imaging resumed MTX therapy without any sequels. No risk factors were found for high-dose MTX-related toxicity occurrence. CONCLUSIONS The time of risk of neurotoxicity due to high-dose MTX treatment for osteosarcoma is days 5-10 following two sequential treatment cycles. These findings together with treatment options for these adverse effects should be detailed in the therapeutic protocol of MTX use among pediatric patients with osteosarcoma.
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Affiliation(s)
- Yair Peled
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Levin
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shelly Shiran
- Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Michal Manisterski
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Shukrun
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Elhasid
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel. .,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Maehara R, Kawamata Y, Ichikawa M, Mitani K, Yasui-Furukori N, Shimoda K. Suicide attempt induced by drug-induced leukoencephalopathy: A case report. Neuropsychopharmacol Rep 2021; 41:551-553. [PMID: 34652886 PMCID: PMC8698666 DOI: 10.1002/npr2.12214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/24/2021] [Accepted: 09/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background Leukoencephalopathy is identified during the administration of anticancer drugs. Symptoms vary from neurological symptoms to psychiatric symptoms depending on the site of damage. There have been no previous reports of suicide attempts due to drug‐induced leukoencephalopathy. Case Presentation The patient was diagnosed with diffuse large B‐cell lymphoma (DLBCL) infiltrating the pharyngeal lesion. Rituximab + methotrexate + oncovin + procarbazine (R‐MPV) therapy, a methotrexate‐containing chemotherapy, was initiated. At the end of the fifth course, the patient attempted suicide by hanging with an appliance cord, which was associated with delusion. A head MRI scan showed no evidence of lymphoma recurrence, but white matter lesions around the ventricles showed progression. Conclusion We report the case of a patient in whom drug‐induced leukoencephalopathy related to methotrexate led to a suicide attempt. In addition to monitoring brain tumors, daily monitoring of psychiatric and neurological symptoms is important for patients with methotrexate‐induced encephalopathy. MRI images revealed that the white matter lesions had progressed even after methotrexate administration was completed. The image taken after one dose of methotrexate also shows mild progression of white matter lesions.![]()
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Affiliation(s)
- Ryo Maehara
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Yasushi Kawamata
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Motoshi Ichikawa
- Department of Hematology and Oncology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Kinuko Mitani
- Department of Hematology and Oncology, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Kazutaka Shimoda
- Department of Psychiatry, Dokkyo Medical University School of Medicine, Tochigi, Japan
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Rubin MF, Kuhn AK. Management of methotrexate-induced neurotoxicity with aminophylline plus dextromethorphan in a pediatric patient with pineoblastoma. Pediatr Blood Cancer 2020; 67:e28515. [PMID: 32710710 DOI: 10.1002/pbc.28515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Mara Faye Rubin
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio
| | - Alexis K Kuhn
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
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