Acute disseminated encephalomyelitis mimicking late CNS relapse of acute lymphoblastic leukaemia: case report

Two Cases of Juvenile Myelomonocytic Leukemia and Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease

BACKGROUND

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is an autoimmune demyelinating disorder that often manifests after infections or vaccinations. We report two patients who developed MOGAD out of eight patients with juvenile myelomonocytic leukemia (JMML) that has never been reported.

METHODS

We investigated two patients with JMML who developed MOGAD among 127 patients with leukemia from 2012 to 2021.

RESULTS

Patient 1 was treated for JMML and developed fever and impaired consciousness at two years and one month of age. Magnetic resonance imaging revealed high-intensity lesions in the left frontal and left occipital white matter. The serum anti-MOG antibody test was positive, while the test was negative in the stored serum 45 days before the onset of encephalopathy. He had relapse of MOGAD after steroid therapy and plasmapheresis. Patient 2, who was treated for JMML, became apathetic and mute at three years and seven months of age. Magnetic resonance imaging revealed left frontoparietal subcortical high-intensity lesions. Anti-MOG antibody at the onset of encephalopathy was positive, while it was negative in stored serum 57 days before and 47 days after the onset.

CONCLUSION

We treated two patients who developed MOGAD out of eight patients with JMML and none with MOGAD out of 119 patients with acute lymphocytic leukemia, acute myelocytic leukemia, or chronic myelocytic leukemia. The activated autoimmune process via the RAS pathway abnormality may have led to the formation of the anti-MOG antibody and the onset of MOGAD. MOGAD can occur in children with JMML, and abnormalities of the RAS pathway possibly contribute to its onset.

A narrative review of central nervous system involvement in acute leukemias

Acute leukemias (both myeloid and lymphoblastic) are a group of diseases for which each year more successful therapies are implemented. However, in a subset of cases the overall survival (OS) is still exceptionally low due to the infiltration of leukemic cells in the central nervous system (CNS) and the subsequent formation of brain tumors. The CNS involvement is more common in acute lymphocytic leukemia (ALL), than in adult acute myeloid leukemia (AML), although the rates for the second case might be underestimated. The main reasons for CNS invasion are related to the expression of specific adhesion molecules (VLA-4, ICAM-1, VCAM, L-selectin, PECAM-1, CD18, LFA-1, CD58, CD44, CXCL12) by a subpopulation of leukemic cells, called “sticky cells” which have the ability to interact and adhere to endothelial cells. Moreover, the microenvironment becomes hypoxic and together with secretion of VEGF-A by ALL or AML cells the permeability of vasculature in the bone marrow increases, coupled with the disruption of blood brain barrier. There is a single subpopulation of leukemia cells, called leukemia stem cells (LSCs) that is able to resist in the new microenvironment due to its high adaptability. The LCSs enter into the arachnoid, migrate, and intensively proliferate in cerebrospinal fluid (CSF) and consequently infiltrate perivascular spaces and brain parenchyma. Moreover, the CNS is an immune privileged site that also protects leukemic cells from chemotherapy. CD56/NCAM is the most important surface molecule often overexpressed by leukemic stem cells that offers them the ability to infiltrate in the CNS. Although asymptomatic or with unspecific symptoms, CNS leukemia should be assessed in both AML/ALL patients, through a combination of flow cytometry and cytological analysis of CSF. Intrathecal therapy (ITT) is a preventive measure for CNS involvement in AML and ALL, still much research is needed in finding the appropriate target that would dramatically lower CNS involvement in acute leukemia.

Acute Disseminated Encephalomyelitis in an Incarcerated Adolescent Presents as Acute Psychosis: Case Report and Literature Review

OBJECTIVE

We aimed to describe a case of an incarcerated adolescent with acute disseminated encephalomyelitis (ADEM) presenting as acute psychosis.

METHODS

This was a retrospective case report followed with chart and literature review.

MAIN FINDINGS

An adolescent with ADEM presented with drastic behavior and personality changes that led to her incarceration for serious charges. Acute disseminated encephalomyelitis leads to neuropsychiatric effects and can be seen with magnetic resonance imaging as a large mass effect that may result in a poor prognosis. This adolescent made a full recovery from her left facial droop, slurred speech, and left-sided hemiplegia, and her personality changes were reverted.

CONCLUSIONS

Acute disseminated encephalomyelitis can present as acute psychosis; therefore, clinical suspicion is important when treating patients who have a history of past infectious brain diseases, especially encephalitis. Given the rapid onset of disease, physicians must be knowledgeable of the diagnosis and treatment of ADEM and be vigilant in finding organic causes of acute psychosis.

Lesions of the central nervous system in leukemia: Pathological and magnetic resonance imaging features at presentation in 14 patients

The present study aimed to characterize the specific pathology and magnetic resonance imaging (MRI) findings observed in patients with leukemia with central nervous system (CNS) lesions, and to determine their value in the management of such patients. Lesions of the CNS were observed during and following treatment of leukemia. The data from stereotactic biopsy-proven pathology (12 patients) and MRI examinations (14 patients) were retrospectively evaluated. Proton-magnetic resonance-spectroscopy was performed in three patients. Factors that predisposed to lesions of the CNS were reviewed from the patient medical records. Among the 14 patients, eight had CNS leukemia, four had a CNS infection and two had a neurodegenerative disorder (one leukoencephalopathy and one glial cell hyperplasia). The clinical diagnosis based on clinical symptoms, signs and MRI features was not consistent with the pathological diagnosis in two patients. In one patient, the clinical diagnosis was a CNS infection; however, the patient's pathological diagnosis was CNS leukemia. In the other patient, the clinical diagnosis was CNS leukemia, but the pathological diagnosis was glial cell hyperplasia. CNS lesions in leukemia have a wide range of causes. Apart from the relapse of leukemia in the CNS, there are treatment-associated neurotoxicities and infections that are caused by immunocompromised states. As numerous leukemia-associated CNS lesions are treatable, early diagnosis is essential.

Acute disseminated encephalomyelitis after allogeneic bone marrow transplantation for pure red cell aplasia - a case report and review of the literature

ADEM is a rare inflammatory demyelinating disease of the CNS, which usually presents after a viral infection or a vaccination. We report a 15-yr-old boy who was diagnosed with ADEM after an HLA-identical sibling allogeneic BMT for transfusion-dependent PRCA. His course was complicated with GVHD affecting the skin and lungs. Five months post-BMT, he developed neurological symptoms including sudden mental status alteration, dysarthria, facial nerve palsy, and acute paraplegia. The MRI revealed multifocal hyperintense lesions mainly in the subcortical white matter of the cerebrum, the brainstem, the basal ganglia, and the thalami. CSF examination was normal. There was no laboratory evidence of infection. The typical MRI findings and an acute monophasic clinical course were consistent with the diagnosis of ADEM. Clinical and radiological improvement was observed after treatment with high-dose steroids and IVIG. Complete neurologic recovery was achieved six months after the onset of symptoms. We present a rare case of ADEM post-BMT and review of the literature.

Diagnosis of acute leukemia in cerebrospinal fluid (CSF-acute leukemia)

Cerebrospinal fluid-acute leukemia (CSF-acute leukemia) is a frequent and serious complication in patients with acute leukemia. One of the major problems of this complication is the diagnosis process itself. CSF cytology is currently considered the gold standard for establishing the diagnosis, a technique which presents various processing limitations, seriously impacting the predictive values. In the last 11 years, studies of CSF flow cytometry analysis done in patients with acute leukemia have demonstrated superiority in comparison with CSF cytology. Although comparative studies between these two techniques have been reported since 2001, no new consensus or formal changes to the gold standard have been established for the CSF acute leukemia diagnosis. The evidence suggests that positive flow cytometry cases, considered as indeterminate cases, will behave like disease in the central nervous system (CNS). Nevertheless, we think there are some variables and considerations that must be first evaluated under research protocols before CNS relapse can be established with only one positive flow cytometry analysis in the setting of indeterminate CSF samples. This paper proposes a diagnostic algorithm and complementary strategies.