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Rhee JY, Nakhate V, Soares C, Tentor Z, Dietrich J. Altered Mental Status in Cancer. Semin Neurol 2024. [PMID: 39102863 DOI: 10.1055/s-0044-1788806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Abstract
Patients with cancer experience high rates of alterations in mental status. The mechanisms for altered mental status (AMS) in this population are manifold. The cancer itself may cause AMS through direct invasion of the central nervous system or as metastatic leptomeningeal spread. However, cancer patients are also vulnerable to tumor-associated complications such as seizures, cerebral edema, strokes, or cancer treatment-related complications such as infections, direct neural injury from radiation or chemotherapy, edema, or dysregulated autoimmune response from immunotherapies. Both during treatment and as sequelae, patients may suffer neurocognitive complications from chemotherapy and radiation, medications or opportunistic infections, as well as toxic-metabolic, nutritional, and endocrine complications. In this review, we describe a clinical approach to the cancer patient presenting with AMS and discuss the differential drivers of AMS in this patient population. While common etiologies of AMS in noncancer patients (toxic-metabolic or infectious encephalopathy, delirium) are also applicable to cancer patients, we additionally provide a cancer-specific differential diagnosis that warrants special consideration in the cancer patient with AMS.
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Affiliation(s)
- John Y Rhee
- Division of Neuro-Oncology, Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Vihang Nakhate
- Division of Neuro-Oncology, Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christy Soares
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Zachary Tentor
- Division of Adult Palliative Care, Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Jorg Dietrich
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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2
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Fominykh V, Averchenkov D, Volik A, Popova E, Bryukhov V, Nazarov V, Moshnikova A, Arzumanian N, Tatarenko A, Nechaev V, Manuylova O, Lapin S, Brylev L, Guekht A. Levamisole-associated multifocal inflammatory encephalopathy: clinical and MRI characteristics, and diagnostic algorithm. Mult Scler Relat Disord 2023; 69:104418. [PMID: 36450175 DOI: 10.1016/j.msard.2022.104418] [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: 10/02/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022]
Abstract
Levamisole-associated multifocal inflammatory encephalopathy (LAMIE) is a devastating adverse effect of levamisole (LEV) treatment. In Russia, people often use LEV without a doctor's prescription for anthelmintic prophylaxis. LAMIE often misdiagnosed as the first episode of MS or acute disseminated encephalomyelitis (ADEM). The aim of our study was to describe clinical, laboratory and morphological characteristics of LAMIE, magnetic resonance imaging (MRI) patterns and create an algorithm for the differential diagnosis. This study was a prospective observational study with retrospective analysis of cases. It was performed at two hospitals with ambulatory service for MS. We included 43 patients with LAMIE with follow-up was from 1 year to 5 years. Age was 19-68 y.o. with female predominance. The most typical manifestations of LAMIE were cerebellar, pyramidal and cognitive symptoms, and majority of patients had biphasic course of the disease. Three main types of MRI patterns were described: ADEM-like, MS-like, atypical demyelination. About 40% of patients had CSF specific oligoclonal bands synthesis, but only 20 % of them converted to MS during the period from 1 month until 2 years. The CSF albumin levels and immunoglobulin G index were elevated in LAMIE patients compared to reference values. We described results of brain biopsy in two cases. Therefore LAMIE should be considered in patients with demyelinating or inflammatory conditions with biphasic onset of the disease and variable MRI presentation.
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Affiliation(s)
- V Fominykh
- Institute of Higher Nervous Activity and Neurophysiology, Butlerova street 5a, Moscow 117485, Russia.
| | - D Averchenkov
- Bujanov Moscow City Clinical Hospital, Moscow, Russia
| | - A Volik
- Institute of Higher Nervous Activity and Neurophysiology, Butlerova street 5a, Moscow 117485, Russia; Federal State Budget Educational Institution of Higher Education M.V.Lomonosov Moscow State University, Moscow, Russia
| | - E Popova
- City Clinical Hospital № 24, Moscow, Russia
| | - V Bryukhov
- Research Center of Neurology, Moscow, Russia
| | - V Nazarov
- Research Center of Neurology, Moscow, Russia; Pavlov First Saint Petersburg Medical University, Saint Petersburg, Russia
| | - A Moshnikova
- Pavlov First Saint Petersburg Medical University, Saint Petersburg, Russia
| | - N Arzumanian
- Bujanov Moscow City Clinical Hospital, Moscow, Russia
| | - A Tatarenko
- Bujanov Moscow City Clinical Hospital, Moscow, Russia
| | - V Nechaev
- Bujanov Moscow City Clinical Hospital, Moscow, Russia
| | - O Manuylova
- Bujanov Moscow City Clinical Hospital, Moscow, Russia
| | - S Lapin
- Pavlov First Saint Petersburg Medical University, Saint Petersburg, Russia
| | - L Brylev
- Institute of Higher Nervous Activity and Neurophysiology, Butlerova street 5a, Moscow 117485, Russia; Bujanov Moscow City Clinical Hospital, Moscow, Russia; Moscow Research and Clinical Center for Neuropsychiatry, Moscow Healthcare Department, Russia
| | - A Guekht
- Moscow Research and Clinical Center for Neuropsychiatry, Moscow Healthcare Department, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
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Tollens N, Post P, Martins Dos Santos M, Niggemann P, Warken M, Wolf J. Multifocal leukoencephalopathy associated with intensive use of cocaine and the adulterant levamisole in a 29-year old patient. Neurol Res Pract 2022; 4:38. [PMID: 35909197 PMCID: PMC9341090 DOI: 10.1186/s42466-022-00202-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
AbstractLevamisole is a common adulterant of cocaine and has been associated with reversible leukoencephalopathy in cocaine users. We report a case of two episodes with severe neurological symptoms and multifocal white matter lesions with brainstem and cerebellar involvement in a 29-year-old man after sporadic cocaine consumption. A urinalysis was positive for levamisole. Neurological deficits as well as MRI presentation improved after cessation of levamisole exposure and two courses of intravenous high-dose glucocorticoid therapy. Early diagnosis of levamisole-induced multifocal leukoencephalopathy and treatment with corticosteroids without delay is essential for a good recovery from neurological symptoms. Although cocaine is one of the most prevalent abused illicit drugs, cocaine- and levamisole-induced multifocal leukoencephalopathy is underdiagnosed as this disorder is not often described in the literature and anamnesis of drug abuse is not admitted by the patient. Therefore, an additional screening for cocaine and levamisole in clinical practice is useful in similar cases to support the diagnosis.
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Jacob A, Sekkath Veedu J, Selene I, Raj R, Kannan L, Patel R. Case report: Uridine triacetate in the management of delayed onset 5-fluorouracil toxicity: A case report and review of literature. Front Pharmacol 2022; 13:977734. [PMID: 36160401 PMCID: PMC9490183 DOI: 10.3389/fphar.2022.977734] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
5-fluorouracil (5FU) and capecitabine are fluoropyrimidine anti-neoplastic drugs commonly used in the treatment of different types of cancer. Hereditary dihydropyrimdine deaminase (DPD), thymidylate synthase mutations and drug overdose may lead to life-threatening toxicities. Uridine triacetate (UTA) is an emergency treatment for overdoses and early onset, severe or life-threatening toxicities from fluoropyrimidines. It is approved for use in adults and children within 96 h of last fluoropyrimidine administration. We present the case of a 64-year-old male treated with 5-FU and oxaliplatin as adjuvant systemic therapy for stage IIIA rectal cancer who developed delayed central nervous system toxicity 18 days after initiating chemotherapy. He had rapidly worsening encephalopathy and ataxia. Laboratory workups, MRI brain and EEG were negative. He was started on UTA with concerns of 5-FU toxicity due to the life-threatening nature of his condition even beyond the recommended 96-h time cut-off. He had rapid improvement in clinical status and resolution of encephalopathy. DPD deficiency testing later resulted as heterozygous for IVS14+1G>A allele indicating enzyme deficiency. This report demonstrates the importance of identifying delayed side effects with fluoropyrimidine therapy and potential treatment for reversing these effects. We also did an extensive literature review and obtained reports from the uridine triacetate clinical trials on patients receiving UTA after the 96-h cut-off. Based on our experience and previous published reports, a patient developing life-threatening delayed 5-FU toxicity should also be considered for UTA on a case-by-case basis.
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Affiliation(s)
- Aasems Jacob
- Department of Hematology and Oncology, Pikeville Medical Center, Pikeville, KY, United States
- *Correspondence: Aasems Jacob,
| | - Janeesh Sekkath Veedu
- Division of Medical Oncology, Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Insija Selene
- Division of Medical Oncology, Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
| | - Rishi Raj
- Department of Endocrinology, Pikeville Medical Center, Pikeville, KY, United States
| | - Lakshmi Kannan
- Department of Nephrology, Pikeville Medical Center, Pikeville, KY, United States
| | - Reema Patel
- Division of Medical Oncology, Department of Internal Medicine, University of Kentucky, Lexington, KY, United States
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Savchuk S, Monje M. Mini-Review: Aplastic Myelin Following Chemotherapy. Neurosci Lett 2022; 790:136861. [PMID: 36055447 DOI: 10.1016/j.neulet.2022.136861] [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: 12/09/2021] [Revised: 05/12/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022]
Abstract
The contribution of chemotherapy to improved outcomes for cancer patients is unquestionable. Yet as its applications broaden, so do the concerns for the long-term implications of chemotherapy on the health of cancer survivors, with chemotherapy-related cognitive impairment as a cause for particular urgency. In this mini review, we explore myelin aplasticity following chemotherapy, discussing the role of myelin plasticity in healthy cognition and failure of myelin plasticity chiefly due microenvironmental aberrations in chemotherapy-related cognitive impairment. Possible therapeutic strategies to mitigate chemotherapy-induced myelin dysfunction are also discussed.
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Affiliation(s)
- Solomiia Savchuk
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, 94305, USA
| | - Michelle Monje
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, 94305, USA; Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, 94305, USA; Department of Neurosurgery, Stanford University, Stanford, CA, 94305, USA; Department of Pathology, Stanford University, Stanford, CA, 94305, USA; Department of Pediatrics, Stanford University, Stanford, CA, 94305, USA; Howard Hughes Medical Institute, Stanford University, Stanford, CA, 94305, USA.
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Michels L, Moisa M, Stämpfli P, Hirsiger S, Baumgartner MR, Surbeck W, Seifritz E, Quednow BB. The impact of levamisole and alcohol on white matter microstructure in adult chronic cocaine users. Addict Biol 2022; 27:e13149. [PMID: 35394690 PMCID: PMC9287079 DOI: 10.1111/adb.13149] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 11/16/2021] [Accepted: 01/11/2022] [Indexed: 11/29/2022]
Abstract
Previous brain imaging studies with chronic cocaine users (CU) using diffusion tensor imaging (DTI) mostly focused on fractional anisotropy to investigate white matter (WM) integrity. However, a quantitative interpretation of fractional anisotropy (FA) alterations is often impeded by the inherent limitations of the underlying tensor model. A more fine-grained measure of WM alterations could be achieved by measuring fibre density (FD). This study investigates this novel DTI metric comparing 23 chronic CU and 32 healthy subjects. Quantitative hair analysis was used to determine intensity of cocaine and levamisole exposure-a cocaine adulterant with putative WM neurotoxicity. We first assessed the impact of cocaine use, levamisole exposure and alcohol use on group differences in WM integrity. Compared with healthy controls, all models revealed cortical reductions of FA and FD in CU. At the within-patient group level, we found that alcohol use and levamisole exposure exhibited regionally different FA and FD alterations than cocaine use. We found mostly negative correlations of tract-based WM associated with levamisole and weekly alcohol use. Specifically, levamisole exposure was linked with stronger WM reductions in the corpus callosum than alcohol use. Cocaine use duration correlated negatively with FA and FD in some regions. Yet, most of these correlations did not survive a correction for multiple testing. Our results suggest that chronic cocaine use, levamisole exposure and alcohol use were all linked to significant WM impairments in CU. We conclude that FD could be a sensitive marker to detect the impact of the use of multiple substances on WM integrity in cocaine but also other substance use disorders.
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Affiliation(s)
- Lars Michels
- Department of NeuroradiologyUniversity Hospital ZurichZurichSwitzerland
- Neuroscience Center ZurichUniversity of Zurich and Swiss Federal Institute of Technology ZurichZurichSwitzerland
| | - Marius Moisa
- Zurich Center for Neuroeconomics, Department of NeuroeconomicsUniversity of ZurichZurichSwitzerland
| | - Philipp Stämpfli
- Department of Psychiatry, Psychotherapy, and PsychosomaticsPsychiatric Hospital of the University of ZurichZurichSwitzerland
| | - Sarah Hirsiger
- Experimental and Clinical Pharmacopsychology, Department of Psychiatry, Psychotherapy, and PsychosomaticsPsychiatric Hospital of the University of ZurichZurichSwitzerland
| | - Markus R. Baumgartner
- Center of Forensic Hair Analytics, Institute of Forensic MedicineUniversity of ZurichZurichSwitzerland
| | - Werner Surbeck
- Experimental and Clinical Pharmacopsychology, Department of Psychiatry, Psychotherapy, and PsychosomaticsPsychiatric Hospital of the University of ZurichZurichSwitzerland
| | - Erich Seifritz
- Neuroscience Center ZurichUniversity of Zurich and Swiss Federal Institute of Technology ZurichZurichSwitzerland
- Department of Psychiatry, Psychotherapy, and PsychosomaticsPsychiatric Hospital of the University of ZurichZurichSwitzerland
| | - Boris B. Quednow
- Neuroscience Center ZurichUniversity of Zurich and Swiss Federal Institute of Technology ZurichZurichSwitzerland
- Experimental and Clinical Pharmacopsychology, Department of Psychiatry, Psychotherapy, and PsychosomaticsPsychiatric Hospital of the University of ZurichZurichSwitzerland
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Nikolaevna ZM, Vladimirovna ZI, Olegovna KA, Hodzhaevna ZA, Shavkatovna AL, Stanislavovna ZE. Levamisole-Induced Leukoencephalopathy in Russia: Analysis of 30 Cases. Curr Drug Saf 2021; 17:319-326. [PMID: 34951579 DOI: 10.2174/1574886317666211224121517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/18/2021] [Accepted: 10/31/2021] [Indexed: 11/22/2022]
Abstract
AIMS To raise medical specialists' awareness regarding the severity of possible complications of levamisole administration and demonstrate the role of accurate medical history collection in differential diagnosis. BACKGROUND Levamisole, an anthelmintic drug with immunomodulatory effects, has long been used worldwide till early 2000s, when its association with demyelinating leukoencephalopathy was established. However, in the developing countries it is still widely used for prevention and treatment of helminthic invasion in humans. Actual prevalence of levamisole-induced multiple inflammatory leukoencephalopathy (LEV-induced MIL) in Russia remains unknown, and therefore, the study of its frequency and characteristics is indisputably important. OBJECTIVES To determine the clinical features and MRI findings of levamisole-induced MIL in the Russian population and to analyse the frequency of diagnostic errors at the initial assessment. METHODS A single-center retrospective analysis of total 30 patients who were diagnosed with LEV-induced MIL and attended Research Center of Neurology was conducted. Inclusion criteria were 1) clinically: acute or subacute polysymptomatic onset of neurological disturbances, 2) MRI: multifocal demyelinating lesion with no evidence of dissemination in time, 3) anamnestic data: levamisole exposure from 2 to 8 weeks before symptoms onset as well as monophasic disease course (absence of relapses according to follow up assessments up to 3 years). RESULTS Clinically, presentation with constitutional symptoms, including headache, fever, fatigue and myalgia, focal motor disturbances and dysarthria prevailed in our cohort. On the brain MRI, multiple foci of demyelination with simultaneous gadolinium enhancement were observed. The link between neurological symptoms and levamisole intake has often been detected only during follow-up assessments. Patients were most often misdiagnosed with acute disseminated encephalomyelitis, stroke and multiple sclerosis. In most cases LEV-induced MIL was successfully treated with intravenous corticosteroids and/or plasma exchange (PLEX), however, residual neurologic symptoms preserved in some patients. Additionally, two detailed clinical cases of patients being initially misdiagnosed are presented in the article. CONCLUSION The differential diagnosis remains difficult for suspected cases of LEV-induced MIL that could lead to delayed therapy initiation, and consequently incomplete recovery. Growing evidence suggests that a single administration of levamisole even in low doses might potentially lead to severe neurological deficit or death. Therefore, changes in medication management policies are required in order to prevent uncontrolled use of levamisole.
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Campillo JT, Eiden C, Boussinesq M, Pion SDS, Faillie JL, Chesnais CB. Adverse reactions with levamisole vary according to its indications and misuse: a systematic pharmacovigilance study. Br J Clin Pharmacol 2021; 88:1094-1106. [PMID: 34390273 PMCID: PMC9293185 DOI: 10.1111/bcp.15037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 11/28/2022] Open
Abstract
AIM Levamisole was initially prescribed for the treatment of intestinal worms. Because of immunomodulatory properties, levamisole has been used in inflammatory pathologies and in cancers in association with 5-fluorouracil. Levamisole is misused as a cocaine adulterant. Post-marketing reports have implicated levamisole in the occurrence of adverse drug reactions (ADRs) and its use is now limited in Europe and North America. In contrast, all other parts of the World continue to use single-dose as an anthelmintic. The aim of this study was to identify ADRs reported after levamisole exposure in VigiBase, the WHO's pharmacovigilance database, and analyze their frequency compared to other drugs and according to levamisole type of use. METHODS All levamisole-related ADRs were extracted from VigiBase®. Disproportionality analyses were conducted to investigate psychiatric, hepatobiliary, renal, vascular, nervous, blood, skin, cardiac, musculoskeletal and general ADRs associated with levamisole and other drugs exposure. In secondary analyses, we compared the frequency of ADRs between levamisole and mebendazole and between levamisole type of use. RESULTS Among the 1763 levamisole-related ADRs identified, psychiatric disorders (Reporting Odds-Ratio with 95% confidence intervals: 1.4 [1.2-2.6]), hepatobiliary disorders (2.4 [1.9-4.3]), vasculitis (6.5 [4.1-10.6]), encephalopathy (22.5 [17.4-39.9]), neuropathy (4.3 [2.9-7.1]), hematological disorders, mild rashes and musculoskeletal disorders were more frequently reported with levamisole than with other drug. The majority of levamisole-related ADRs occurred when the drug was administrated for a non-anti-infectious indication. CONCLUSION The great majority of the levamisole-related ADRs concerned its immunomodulatory indication and multiple doses regimen. Our results suggest that single-dose treatments for anthelmintic action have a good safety profile.
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Affiliation(s)
- Jérémy T Campillo
- UMI 233, Institut de Recherche pour le Développement (IRD), Montpellier, France.,Université de Montpellier, Montpellier, France.,INSERM Unité 1175, Montpellier, France
| | - Céline Eiden
- Department of medical pharmacology and toxicology, CHU Montpellier, Montpellier, France
| | - Michel Boussinesq
- UMI 233, Institut de Recherche pour le Développement (IRD), Montpellier, France.,Université de Montpellier, Montpellier, France.,INSERM Unité 1175, Montpellier, France
| | - Sébastien D S Pion
- UMI 233, Institut de Recherche pour le Développement (IRD), Montpellier, France.,Université de Montpellier, Montpellier, France.,INSERM Unité 1175, Montpellier, France
| | - Jean-Luc Faillie
- Department of medical pharmacology and toxicology, CHU Montpellier, Montpellier, France.,Desbrest Institute of Epidemiology and Public Health UMR UA11 INSERM, University of Montpellier, Montpellier, France
| | - Cédric B Chesnais
- UMI 233, Institut de Recherche pour le Développement (IRD), Montpellier, France.,Université de Montpellier, Montpellier, France.,INSERM Unité 1175, Montpellier, France
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Conrad F, Hirsiger S, Winklhofer S, Baumgartner MR, Stämpfli P, Seifritz E, Wegener S, Quednow BB. Use of levamisole-adulterated cocaine is associated with increased load of white matter lesions. J Psychiatry Neurosci 2021; 46:E281-E291. [PMID: 33844483 PMCID: PMC8061741 DOI: 10.1503/jpn.200057] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 09/17/2020] [Accepted: 09/29/2020] [Indexed: 12/03/2022] Open
Abstract
Background Cocaine use has been associated with vascular pathologies, including cerebral white matter hyperintensities. Street cocaine is most often adulterated with levamisole, an anthelminthic drug that may also be associated with vascular toxicity. However, whether levamisole exposure from cocaine consumption further accelerates the development of white matter lesions remains unknown. Methods We investigated the association of cocaine and levamisole exposure with white matter hyperintensities in 35 chronic cocaine users and 34 healthy controls. We measured cocaine and levamisole concentrations in hair samples, which reflected exposure up to 6 months previously. We assessed the number and total surface area of the white matter hyperintensities using structural MRI (FLAIR sequence). Using generalized linear models, we analyzed the contributions of cocaine and levamisole to the number and area of white matter hyperintensities, accounting for several confounding factors. Results Analysis using generalized linear models revealed that cocaine users had more white matter hyperintensities in terms of total surface area, but not in terms of number. Further generalized linear models that included cocaine and levamisole hair concentrations (instead of group) as predictors indicated that levamisole exposure was strongly associated with more and larger white matter hyperintensities, suggesting that the elevated white matter hyperintensities in cocaine users were driven mainly by levamisole exposure. Finally, white matter hyperintensities in levamisole-exposed cocaine users were located primarily in the periventricular and juxtacortical white matter. Limitations The sample size was moderate, and blood pressure was not systematically assessed. Conclusion As an adulterant of cocaine, levamisole appears to increase the risk of white matter injury.
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Affiliation(s)
- Florian Conrad
- From the Department of Neurology, University Hospital Zurich, University of Zurich, Switzerland (Conrad, Wegener); the Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital, University of Zurich, Switzerland (Hirsiger, Stämpfli, Seifritz, Quednow); the Department of Neuroradiology, University Hospital Zürich, University of Zurich, Switzerland (Winklhofer); the Center of Forensic Hair Analytics, Institute of Forensic Medicine, University of Zurich, Switzerland (Baumgartner); and the Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland (Seifritz, Wegener, Quednow)
| | - Sarah Hirsiger
- From the Department of Neurology, University Hospital Zurich, University of Zurich, Switzerland (Conrad, Wegener); the Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital, University of Zurich, Switzerland (Hirsiger, Stämpfli, Seifritz, Quednow); the Department of Neuroradiology, University Hospital Zürich, University of Zurich, Switzerland (Winklhofer); the Center of Forensic Hair Analytics, Institute of Forensic Medicine, University of Zurich, Switzerland (Baumgartner); and the Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland (Seifritz, Wegener, Quednow)
| | - Sebastian Winklhofer
- From the Department of Neurology, University Hospital Zurich, University of Zurich, Switzerland (Conrad, Wegener); the Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital, University of Zurich, Switzerland (Hirsiger, Stämpfli, Seifritz, Quednow); the Department of Neuroradiology, University Hospital Zürich, University of Zurich, Switzerland (Winklhofer); the Center of Forensic Hair Analytics, Institute of Forensic Medicine, University of Zurich, Switzerland (Baumgartner); and the Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland (Seifritz, Wegener, Quednow)
| | - Markus R Baumgartner
- From the Department of Neurology, University Hospital Zurich, University of Zurich, Switzerland (Conrad, Wegener); the Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital, University of Zurich, Switzerland (Hirsiger, Stämpfli, Seifritz, Quednow); the Department of Neuroradiology, University Hospital Zürich, University of Zurich, Switzerland (Winklhofer); the Center of Forensic Hair Analytics, Institute of Forensic Medicine, University of Zurich, Switzerland (Baumgartner); and the Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland (Seifritz, Wegener, Quednow)
| | - Philipp Stämpfli
- From the Department of Neurology, University Hospital Zurich, University of Zurich, Switzerland (Conrad, Wegener); the Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital, University of Zurich, Switzerland (Hirsiger, Stämpfli, Seifritz, Quednow); the Department of Neuroradiology, University Hospital Zürich, University of Zurich, Switzerland (Winklhofer); the Center of Forensic Hair Analytics, Institute of Forensic Medicine, University of Zurich, Switzerland (Baumgartner); and the Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland (Seifritz, Wegener, Quednow)
| | - Erich Seifritz
- From the Department of Neurology, University Hospital Zurich, University of Zurich, Switzerland (Conrad, Wegener); the Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital, University of Zurich, Switzerland (Hirsiger, Stämpfli, Seifritz, Quednow); the Department of Neuroradiology, University Hospital Zürich, University of Zurich, Switzerland (Winklhofer); the Center of Forensic Hair Analytics, Institute of Forensic Medicine, University of Zurich, Switzerland (Baumgartner); and the Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland (Seifritz, Wegener, Quednow)
| | - Susanne Wegener
- From the Department of Neurology, University Hospital Zurich, University of Zurich, Switzerland (Conrad, Wegener); the Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital, University of Zurich, Switzerland (Hirsiger, Stämpfli, Seifritz, Quednow); the Department of Neuroradiology, University Hospital Zürich, University of Zurich, Switzerland (Winklhofer); the Center of Forensic Hair Analytics, Institute of Forensic Medicine, University of Zurich, Switzerland (Baumgartner); and the Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland (Seifritz, Wegener, Quednow)
| | - Boris B Quednow
- From the Department of Neurology, University Hospital Zurich, University of Zurich, Switzerland (Conrad, Wegener); the Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric University Hospital, University of Zurich, Switzerland (Hirsiger, Stämpfli, Seifritz, Quednow); the Department of Neuroradiology, University Hospital Zürich, University of Zurich, Switzerland (Winklhofer); the Center of Forensic Hair Analytics, Institute of Forensic Medicine, University of Zurich, Switzerland (Baumgartner); and the Neuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Switzerland (Seifritz, Wegener, Quednow)
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10
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Allard J, Ancelet C, Denier C. Cocaine and Levamisole Cerebral Toxicity. Ann Neurol 2021; 89:1253-1254. [PMID: 33527459 DOI: 10.1002/ana.26035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Julien Allard
- Department of Neurology, University Hospital of Bicêtre, Le Kremlin-Bicêtre, France
| | - Claire Ancelet
- Department of Neuroradiology, University Hospital of Bicêtre, Le Kremlin-Bicêtre, France
| | - Christian Denier
- Department of Neurology, University Hospital of Bicêtre, Le Kremlin-Bicêtre, France
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11
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Averchenkov D, Volik A, Fominykh V, Nazarov V, Moshnikova A, Lapin S, Brylev L, Guekht A. Acute disseminated encephalomyelitis. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:119-128. [DOI: 10.17116/jnevro2021121111119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Younger DS. Cerebral vasculitis associated with drug abuse. Curr Opin Rheumatol 2021; 33:24-33. [PMID: 33186242 DOI: 10.1097/bor.0000000000000766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review understand the epidemiology, background, neuropharmacology, and histopathology of literature verified cases, and likely etiopathogenic mechanisms. RECENT FINDINGS There are only a handful of histologically confirmed patients in the literature with cerebral vasculitis because of drug abuse. SUMMARY There is little justification for invasive laboratory investigation given the ready availability of highly accurate vascular neuroimaging techniques to dictate management, which usually rests upon avoidance of further exposure and minimizing the secondary neurotoxic effects of the abused substances and polypharmacy use.
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Affiliation(s)
- David S Younger
- City University of New York Medical School, New York, New York, USA
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13
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Belova AN, Solovieva VS, Rasteryaeva MV, Belova EM. [Multifocal inflammatory levamisole-induced leukoencephalopathy]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:89-96. [PMID: 32844637 DOI: 10.17116/jnevro202012007289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Levamisole (L) is an anthelmintic agent that is widely used in clinical practice. L can enter the human organism during the treatment of helminthiasis as well as during the using the contaminated cocaine. Multifocal inflammatory levamisole-induced leukoencephalopathy (MILL) is one of the most serious complications of L use. The article discusses the clinical and radiological features of MILL which have a number of similarities of multiple sclerosis (MS) appearance. The disease has a favorable prognosis if started early, but the diagnosis of this rare form of leukoencephalopathy can cause difficulties. The case of MILL in patient with mistaken diagnosis of MS is descrThe case of MILL in patient with mistaken diagnosis of MS is descraibed.ibed.
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Affiliation(s)
- A N Belova
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - V S Solovieva
- City Clinical Hospital No. 3, Nizhny Novgorod, Russia
| | - M V Rasteryaeva
- Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - E M Belova
- City Clinical Hospital No. 3, Nizhny Novgorod, Russia
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14
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Grasso D, Borreggine C, Castorani G, Vergara D, Dimitri LMC, Catapano D, Simeone A, Popolizio T. Balò's concentric sclerosis in a case of cocaine-levamisole abuse. SAGE Open Med Case Rep 2020; 8:2050313X20940532. [PMID: 32733680 PMCID: PMC7370552 DOI: 10.1177/2050313x20940532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/17/2020] [Indexed: 01/15/2023] Open
Abstract
Baló’s concentric sclerosis is a rare variant of multiple sclerosis. It belongs to the group of primary inflammatory central nervous system demyelinating diseases having no clear etiology. Peculiar radiological findings on magnetic resonance imaging are alternating rings of demyelinated and myelinated axons resembling an “onion bulb.” We report on a case of a patient with cocaine abuse who presented with Balò’s-like acute multifocal leukoencephalopathy supported by histological and radiological findings. The abuse of cocaine and its most frequent adulterant, levamisole, may induce ischemic or hemorrhagic stroke and metabolic or multifocal inflammatory leukoencephalopathy. Only a few studies described levamisole-induced leukoencephalopathy mimicking Balò round lesions. Nevertheless, it has not yet been established the correlation between them; it might also be possible that the cocaine/levamisole addiction represents just a coincidence in some of those patients affected by Balò sclerosis disease.
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Affiliation(s)
- Daniela Grasso
- Department of Diagnostic Imaging, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Carmela Borreggine
- Department of Diagnostic Imaging, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Giulia Castorani
- Diagnostic Imaging, Postgraduate Medical School, University of Foggia, Foggia, Italy
| | - Doriana Vergara
- Department of Diagnostic Imaging, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | | | - Domenico Catapano
- Complex Operative Unit of Neurosurgery, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Annalisa Simeone
- Department of Diagnostic Imaging, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Teresa Popolizio
- Department of Diagnostic Imaging, IRCCS Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
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15
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Averchenkov DM, Bejsheeva MT, Ivakina ED, Fominykh VV, Grazhdantseva LY, Ivashchenko RA, Arzumanian NS, Brylev LV, Guekht AB. [Clinical case of levamisole-induced multifocal inflammatory leukoencephalopathy]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 119:106-114. [PMID: 31994523 DOI: 10.17116/jnevro2019119121106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Levamisole is an immunomodulatory drug which can trigger development of levamisole-induced multifocal inflammatory leukoencephalopathy (LIMIL) in patients treated for helminthic invasion, aphthous stomatitis, cancer, or cocaine users. LIMIL clinical case in patient 45 years old after single dose of levamisole (taken without any medical prescription) was described. We presented clinical history and clinical picture, MRI and laboratory data and treatment results during 1-year observation. According to similarity of LIMIL with acute disseminating encephalomyelitis or debut of multiple sclerosis and high frequency of levamisole usage in Russia (usually without medical prescription) LIMIL should be included in differential diagnosis in demyelinating disorders and treated according to current clinical recommendation.
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Affiliation(s)
| | - M T Bejsheeva
- Bujanov Moscow City Clinical Hospital, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia
| | - E D Ivakina
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - V V Fominykh
- Bujanov Moscow City Clinical Hospital, Moscow, Russia; Institute of Higher Nervous Activity and Neurophysiology, Moscow, Russia
| | | | | | | | - L V Brylev
- Bujanov Moscow City Clinical Hospital, Moscow, Russia; Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
| | - A B Guekht
- Bujanov Moscow City Clinical Hospital, Moscow, Russia; Pirogov Russian National Research Medical University, Moscow, Russia; Moscow Research and Clinical Center for Neuropsychiatry, Moscow, Russia
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16
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Abstract
Illicit drug abuse is a common differential diagnosis of acquired central nervous system vasculitis even though there are only a handful of histopathologically confirmed patients in the literature from among the many potential classes of abused drugs traditionally implicated in this disease. This article considers the major classes of illicit drugs in those with and without human immunodeficiency virus type-1 infection and acquired immune deficiency syndrome.
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Affiliation(s)
- David S Younger
- Department of Neurology, Division of Neuro-Epidemiology, New York University School of Medicine, New York, NY, USA; School of Public Health, City University of New York, New York, NY, USA.
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17
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Vonmoos M, Hirsiger S, Preller KH, Hulka LM, Allemann D, Herdener M, Baumgartner MR, Quednow BB. Cognitive and neuroanatomical impairments associated with chronic exposure to levamisole-contaminated cocaine. Transl Psychiatry 2018; 8:235. [PMID: 30368522 PMCID: PMC6204136 DOI: 10.1038/s41398-018-0279-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 08/29/2018] [Accepted: 09/10/2018] [Indexed: 01/07/2023] Open
Abstract
Currently, levamisole is the most common cocaine adulterant worldwide and it is known to induce a variety of adverse side effects. Animal studies and human case reports suggest potential neurotoxicity of the compound but neither neuroanatomical nor cognitive effects of levamisole have been systematically investigated in cocaine users so far. We examined cognitive performance and cortical structural differences between chronic cocaine users with low and high recent exposure to levamisole objectively determined by quantitative toxicological hair analyses. In Study 1, we compared 26 chronic cocaine users with low levamisole exposure (lowLevCU), 49 matched cocaine users with high levamisole exposure (highLevCU), and 78 matched stimulant-naive controls regarding cognitive functioning employing a comprehensive neuropsychological test battery. In Study 2, we investigated cortical thickness by use of T1-weighted MRI in a subgroup of 12 lowLevCU, 17 highLevCU, and 38 stimulant-naive controls. In Study 1, both cocaine user groups showed significant impairments in the cognitive domains of attention and working memory as well as in the global cognitive index. However, highLevCU showed significantly worse executive functions compared to lowLevCU although both groups did not differ in severity of cocaine consumption and other clinical dimensions. Study 2 revealed that highLevCU, displayed reduced cortical thickness specifically in the middle frontal gyrus compared to both controls and lowLevCU. Our results suggest that levamisole exposure during the last months in cocaine users is associated with increased executive function impairments and pronounced thinning of the lateral prefrontal cortex. Consequently, prevention and drug policy-making should aim to reduce levamisole contamination of street cocaine.
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Affiliation(s)
- Matthias Vonmoos
- Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric Hospital, Experimental and Clinical Pharmacopsychology, University of Zurich, Zurich, Switzerland.
| | - Sarah Hirsiger
- 0000 0004 1937 0650grid.7400.3Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric Hospital, Experimental and Clinical Pharmacopsychology, University of Zurich, Zurich, Switzerland
| | - Katrin H. Preller
- 0000 0004 1937 0650grid.7400.3Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric Hospital, Experimental and Clinical Pharmacopsychology, University of Zurich, Zurich, Switzerland
| | - Lea M. Hulka
- 0000 0004 1937 0650grid.7400.3Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric Hospital, Experimental and Clinical Pharmacopsychology, University of Zurich, Zurich, Switzerland ,0000 0004 1937 0650grid.7400.3Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric Hospital, Center for Addictive Disorders, University of Zurich, Zurich, Switzerland
| | - Daniel Allemann
- Health & Social Welfare Department State of Berne, Office of the Cantonal Pharmacist, Zurich, Switzerland
| | - Marcus Herdener
- 0000 0004 1937 0650grid.7400.3Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric Hospital, Center for Addictive Disorders, University of Zurich, Zurich, Switzerland
| | - Markus R. Baumgartner
- 0000 0004 1937 0650grid.7400.3Center of Forensic Hairanalytics, Institute of Forensic Medicine, University of Zurich, Zurich, Switzerland
| | - Boris B. Quednow
- 0000 0004 1937 0650grid.7400.3Department of Psychiatry, Psychotherapy, and Psychosomatics, Psychiatric Hospital, Experimental and Clinical Pharmacopsychology, University of Zurich, Zurich, Switzerland ,0000 0001 2156 2780grid.5801.cNeuroscience Center Zurich, University of Zurich and Swiss Federal Institute of Technology Zurich, Zurich, Switzerland
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18
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Cocaine/levamisole-associated autoimmune syndrome: a disease of neutrophil-mediated autoimmunity. Curr Opin Hematol 2018; 25:29-36. [PMID: 29211697 DOI: 10.1097/moh.0000000000000393] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Levamisole was previously used for its immunomodulatory properties to treat rheumatoid arthritis and some cancers. However, because of serious side-effects, it was taken off the market in the United States. Recently, levamisole has reemerged as a popular cocaine adulterant. Some individuals who consume levamisole-adulterated cocaine can develop a life-threatening autoimmune syndrome. In this review, the medical consequences of levamisole exposure and postulated mechanisms by which levamisole induces these adverse effects are discussed. RECENT FINDINGS Although agranulocytosis and cutaneous vasculitis are the major findings in patients who develop cocaine/levamisole-associated autoimmune syndrome (CLAAS), more recent experience indicates that other organ systems can be involved as well. Current studies point to neutrophil activation and neutrophil extracellular trap formation with subsequent antineutrophil cytoplasmic antibody-mediated tissue injury as a possible mechanism of CLAAS. SUMMARY In the past decade, the detrimental effects of levamisole have reemerged because of its popularity as a cocaine adulterant. Although infrequent, some individuals develop a systemic autoimmune syndrome characterized by immune-mediated agranulocytosis and antineutrophil cytoplasmic antibody-mediated vasculitis. Mechanistically, neutrophil antigens appear to be a major player in inducing CLAAS. Prompt cessation of levamisole exposure is key to treatment, although relapses are frequent because of the addictive effects of cocaine and the high prevalence of levamisole within the cocaine supply.
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19
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Zurayk M, Keung YK, Yu D, Hu EHL. Successful use of uridine triacetate (Vistogard) three weeks after capecitabine in a patient with homozygous dihydropyrimidine dehydrogenase mutation: A case report and review of the literature. J Oncol Pharm Pract 2017; 25:234-238. [DOI: 10.1177/1078155217732141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
5-fluorouracil and capecitabine are chemotherapeutic agents commonly used to treat solid malignancies. Increased susceptibility to 5-fluorouracil or capecitabine, caused by impaired clearance, dihydropyrimidine dehydrogenase deficiency, or other genetic mutations in the enzymes that metabolize 5-fluorouracil can lead to severe life-threatening toxicities and are typically manifested by an early onset of symptoms. We report and discuss the management and outcome of capecitabine toxicity with the recently FDA approved antidote, uridine triacetate (Vistogard), in a 57-year-old female breast cancer patient with homozygous dihydropyrimidine dehydrogenase deficiency who received treatment beyond the recommended 96 h window from the last dose of capecitabine.
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Affiliation(s)
- Mira Zurayk
- Department of Pharmacy, Huntington Memorial Hospital, Pasadena, USA
| | | | - David Yu
- Department of Pharmacy, Huntington Memorial Hospital, Pasadena, USA
| | - Eddie HL Hu
- UCLA Hematology-Oncology Clinic, Alhambra, CA, USA
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20
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Vitt JR, Brown EG, Chow DS, Josephson SA. Confirmed case of levamisole-associated multifocal inflammatory leukoencephalopathy in a cocaine user. J Neuroimmunol 2017; 305:128-130. [DOI: 10.1016/j.jneuroim.2017.01.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 01/30/2017] [Indexed: 11/25/2022]
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21
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Adverse effects of levamisole in cocaine users: a review and risk assessment. Arch Toxicol 2017; 91:2303-2313. [DOI: 10.1007/s00204-017-1947-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/23/2017] [Indexed: 10/19/2022]
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22
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Tobin WO, Costanzi C, Guo Y, Parisi JE, Weigand SD, Lucchinetti CF. Clinical-radiological-pathological spectrum of central nervous system-idiopathic inflammatory demyelinating disease in the elderly. Mult Scler 2016; 23:1204-1213. [PMID: 27760861 DOI: 10.1177/1352458516675748] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The spectrum of central nervous system-idiopathic inflammatory demyelinating disease (CNS-IIDD) in the elderly is uncertain. OBJECTIVE To describe the clinical, radiological, and pathological features of a cohort of 30 pathologically proven CNS-IIDD patients ⩾65 years. METHODS Elderly multiple sclerosis (MS)/clinically isolated syndrome (CIS) patients were compared to a cohort of 125 patients with pathologically proven MS/CIS and symptom onset <65 years. RESULTS Median age at symptom onset was 69 years (interquartile range (IQR) = 68-75). Median follow-up was 1.9 years (IQR = 1.0-5.6). Diagnoses were MS (14/30), CIS (11/30), neuromyelitis optica (NMO; 4/30), and acute disseminated encephalomyelitis (ADEM; 1/30). Disability was higher in patients with MS/CIS ⩾65 compared to patients <65 (median Expanded Disability Status Scale (EDSS) 4 (IQR = 2.5-7) vs 2.5 (IQR = 1.5-4); p = 0.002). When compared to patients <65 years, there was no difference in the lesion size, number of patients fulfilling Barkhof's criteria, edema, or mass effect. Confluent demyelination was observed in 27 patients (MS/CIS (23/25), NMO (4)), 2 had a mixed perivenular/confluent pattern (MS (1), ADEM (1)), and 1 patient with MS had a mixed confluent/perivenular/coalescent pattern. Early active lesions were found in 19/30 patients ((MS (4), CIS (13), NMO (2); 53%). Cortical demyelination was present in 7/12 (58%) patients (MS (3), CIS(3), ADEM (1)). CONCLUSION A spectrum of CNS-IIDD can develop in the elderly, with presenting symptoms similar to younger patients. Early diagnosis of CNS demyelinating disease is essential to avoid invasive and disabling procedures.
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Affiliation(s)
- W Oliver Tobin
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Chiara Costanzi
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Yong Guo
- Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Joseph E Parisi
- Department of Pathology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Stephen D Weigand
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, MN, USA
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23
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Vosoughi R, Schmidt BJ. Multifocal leukoencephalopathy in cocaine users: a report of two cases and review of the literature. BMC Neurol 2015; 15:208. [PMID: 26482228 PMCID: PMC4615875 DOI: 10.1186/s12883-015-0467-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/08/2015] [Indexed: 12/03/2022] Open
Abstract
Background Cocaine abuse is associated with several mechanisms of brain injury including ischemic, hemorrhagic and metabolic. Recently two case reports of leukoencephalopathy in cocaine users implicated a commonly used cocaine adulterant, levamisole. One well-documented adverse effect of levamisole, when used alone as antihelminthic or immunomodulatory drug, is multifocal inflammatory leukoencephalopathy. Therefore, immune mechanisms may also contribute to cocaine-induced brain injury. Case presentations Two cocaine users with multifocal leukoencephalopathy, treated with steroids and plasmapheresis, are described. The first is a 25-year-old man who presented with unilateral motor and sensory impairment progressing to bilateral deficits, dysphagia, dysarthria and confusion over several days. Serial MRI showed increasing abnormal FLAIR signal lesions with patchy restricted diffusion and heterogenous enhancement deep in the right and left hemispheres, including periventricular white matter as well as in the pons and cerebellar peduncle. The second patient is a 41-year-old woman who presented with confusion and impaired balance. MRI showed bilateral periventricular FLAIR lesions with scattered restricted diffusion and subtle gadolinium enhancement of some of the lesions. She initially stabilized with supportive care only, but after further cocaine use was re-admitted six weeks later with marked neurological deterioration and MRI showed prominent worsening of the lesions. Both patients received steroid and plasma exchange and showed substantial improvement clinically and on imaging, which was sustained during out-patient follow-up. Conclusion Multifocal leukoencephalopathy associated with cocaine use may have an inflammatory/immune basis, possibly related to levamisole contamination, at least in some patients. Three cases, including the present two, have been described wherein good neurological improvement was seen in association with steroid treatment. However, in the absence of appropriate clinical trials, it remains unknown whether immunotherapy is truly beneficial for these patients.
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Affiliation(s)
- Reza Vosoughi
- Section of Neurology, Department of Internal Medicine, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, R3A 1R9, Canada.
| | - Brian J Schmidt
- Section of Neurology, Department of Internal Medicine, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, R3A 1R9, Canada.
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24
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Vosoughi R, Schmidt BJ. Multifocal leukoencephalopathy in cocaine users: a report of two cases and review of the literature. BMC Neurol 2015. [PMID: 26482228 DOI: 10.1186/s12883-015-0467-1"] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cocaine abuse is associated with several mechanisms of brain injury including ischemic, hemorrhagic and metabolic. Recently two case reports of leukoencephalopathy in cocaine users implicated a commonly used cocaine adulterant, levamisole. One well-documented adverse effect of levamisole, when used alone as antihelminthic or immunomodulatory drug, is multifocal inflammatory leukoencephalopathy. Therefore, immune mechanisms may also contribute to cocaine-induced brain injury. CASE PRESENTATIONS Two cocaine users with multifocal leukoencephalopathy, treated with steroids and plasmapheresis, are described. The first is a 25-year-old man who presented with unilateral motor and sensory impairment progressing to bilateral deficits, dysphagia, dysarthria and confusion over several days. Serial MRI showed increasing abnormal FLAIR signal lesions with patchy restricted diffusion and heterogenous enhancement deep in the right and left hemispheres, including periventricular white matter as well as in the pons and cerebellar peduncle. The second patient is a 41-year-old woman who presented with confusion and impaired balance. MRI showed bilateral periventricular FLAIR lesions with scattered restricted diffusion and subtle gadolinium enhancement of some of the lesions. She initially stabilized with supportive care only, but after further cocaine use was re-admitted six weeks later with marked neurological deterioration and MRI showed prominent worsening of the lesions. Both patients received steroid and plasma exchange and showed substantial improvement clinically and on imaging, which was sustained during out-patient follow-up. CONCLUSION Multifocal leukoencephalopathy associated with cocaine use may have an inflammatory/immune basis, possibly related to levamisole contamination, at least in some patients. Three cases, including the present two, have been described wherein good neurological improvement was seen in association with steroid treatment. However, in the absence of appropriate clinical trials, it remains unknown whether immunotherapy is truly beneficial for these patients.
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Affiliation(s)
- Reza Vosoughi
- Section of Neurology, Department of Internal Medicine, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, R3A 1R9, Canada.
| | - Brian J Schmidt
- Section of Neurology, Department of Internal Medicine, College of Medicine, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, R3A 1R9, Canada.
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25
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Noble M, Mayer-Pröschel M, Li Z, Dong T, Cui W, Pröschel C, Ambeskovic I, Dietrich J, Han R, Yang YM, Folts C, Stripay J, Chen HY, Stevens BM. Redox biology in normal cells and cancer: restoring function of the redox/Fyn/c-Cbl pathway in cancer cells offers new approaches to cancer treatment. Free Radic Biol Med 2015; 79:300-23. [PMID: 25481740 PMCID: PMC10173888 DOI: 10.1016/j.freeradbiomed.2014.10.860] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 10/29/2014] [Accepted: 10/30/2014] [Indexed: 12/12/2022]
Abstract
This review discusses a unique discovery path starting with novel findings on redox regulation of precursor cell and signaling pathway function and identification of a new mechanism by which relatively small changes in redox status can control entire signaling networks that regulate self-renewal, differentiation, and survival. The pathway central to this work, the redox/Fyn/c-Cbl (RFC) pathway, converts small increases in oxidative status to pan-activation of the c-Cbl ubiquitin ligase, which controls multiple receptors and other proteins of central importance in precursor cell and cancer cell function. Integration of work on the RFC pathway with attempts to understand how treatment with systemic chemotherapy causes neurological problems led to the discovery that glioblastomas (GBMs) and basal-like breast cancers (BLBCs) inhibit c-Cbl function through altered utilization of the cytoskeletal regulators Cool-1/βpix and Cdc42, respectively. Inhibition of these proteins to restore normal c-Cbl function suppresses cancer cell division, increases sensitivity to chemotherapy, disrupts tumor-initiating cell (TIC) activity in GBMs and BLBCs, controls multiple critical TIC regulators, and also allows targeting of non-TICs. Moreover, these manipulations do not increase chemosensitivity or suppress division of nontransformed cells. Restoration of normal c-Cbl function also allows more effective harnessing of estrogen receptor-α (ERα)-independent activities of tamoxifen to activate the RFC pathway and target ERα-negative cancer cells. Our work thus provides a discovery strategy that reveals mechanisms and therapeutic targets that cannot be deduced by standard genetics analyses, which fail to reveal the metabolic information, isoform shifts, protein activation, protein complexes, and protein degradation critical to our discoveries.
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Affiliation(s)
- Mark Noble
- Department of Biomedical Genetics and University of Rochester Stem Cell and Regenerative Medicine Institute, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Margot Mayer-Pröschel
- Department of Biomedical Genetics and University of Rochester Stem Cell and Regenerative Medicine Institute, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Zaibo Li
- Department of Pathology, Ohio State University Wexner Medical Center, 410W 10th Avenue, E403 Doan Hall, Columbus, OH 43210-1240, USA.
| | - Tiefei Dong
- University of Michigan Tech Transfer, 1600 Huron Pkwy, 2nd Floor, Building 520, Ann Arbor, MI 48109-2590, USA.
| | - Wanchang Cui
- Department of Radiation Oncology, University of Maryland School of Medicine,10 South Pine Street, MSTF Room 600, Baltimore, MD 21201, USA.
| | - Christoph Pröschel
- Department of Biomedical Genetics and University of Rochester Stem Cell and Regenerative Medicine Institute, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Ibro Ambeskovic
- Department of Biomedical Genetics and University of Rochester Stem Cell and Regenerative Medicine Institute, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Joerg Dietrich
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 9E, Boston, MA 02114, USA.
| | - Ruolan Han
- Department of Biomedical Genetics and University of Rochester Stem Cell and Regenerative Medicine Institute, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Yin Miranda Yang
- Department of Biomedical Genetics and University of Rochester Stem Cell and Regenerative Medicine Institute, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Christopher Folts
- Department of Biomedical Genetics and University of Rochester Stem Cell and Regenerative Medicine Institute, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Jennifer Stripay
- Department of Biomedical Genetics and University of Rochester Stem Cell and Regenerative Medicine Institute, University of Rochester Medical Center, Rochester, NY 14642, USA.
| | - Hsing-Yu Chen
- Harvard Medical School, Department of Cell Biology 240 Longwood Avenue Building C1, Room 513B Boston, MA 02115, USA.
| | - Brett M Stevens
- University of Colorado School of Medicine, Division of Hematology, 12700 E. 19th Avenue, Campus Box F754-AMCA, Aurora, CO 80045, USA.
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Nowak LG, Rosay B, Czégé D, Fonta C. Tetramisole and Levamisole Suppress Neuronal Activity Independently from Their Inhibitory Action on Tissue Non-specific Alkaline Phosphatase in Mouse Cortex. Subcell Biochem 2015. [PMID: 26219715 DOI: 10.1007/978-94-017-7197-9_12] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tissue non-specific alkaline phosphatase (TNAP) may be involved in the synthesis of GABA and adenosine, which are the main inhibitory neurotransmitters in cortex. We explored this putative TNAP function through electrophysiological recording (local field potential ) in slices of mouse somatosensory cortex maintained in vitro. We used tetramisole, a well documented TNAP inhibitor, to block TNAP activity. We expected that inhibiting TNAP with tetramisole would lead to an increase of neuronal response amplitude, owing to a diminished availability of GABA and/or adenosine. Instead, we found that tetramisole reduced neuronal response amplitude in a dose-dependent manner. Tetramisole also decreased axonal conduction velocity. Levamisole had identical effects. Several control experiments demonstrated that these actions of tetramisole were independent from this compound acting on TNAP. In particular, tetramisole effects were not stereo-specific and they were not mimicked by another inhibitor of TNAP, MLS-0038949. The decrease of axonal conduction velocity and preliminary intracellular data suggest that tetramisole blocks voltage-dependent sodium channels. Our results imply that levamisole or tetramisole should not be used with the sole purpose of inhibiting TNAP in living excitable cells as it will also block all processes that are activity-dependent. Our data and a review of the literature indicate that tetramisole may have at least four different targets in the nervous system. We discuss these results with respect to the neurological side effects that were observed when levamisole and tetramisole were used for medical purposes, and that may recur nowadays due to the recent use of levamisole and tetramisole as cocaine adulterants.
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Affiliation(s)
- Lionel G Nowak
- Centre de Recherche Cerveau et Cognition (CerCo), Université de Toulouse UPS; CNRS UMR 5549 , Toulouse, France,
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Dedić Plavetić N, Rakušić Z, Ozretić D, Simetić L, Krpan AM, Bišof V. Fatal outcome of posterior "reversible" encephalopathy syndrome in metastatic colorectal carcinoma after irinotecan and fluoropyrimidine chemotherapy regimen. World J Surg Oncol 2014; 12:264. [PMID: 25142792 PMCID: PMC4143544 DOI: 10.1186/1477-7819-12-264] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 08/06/2014] [Indexed: 11/10/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity characterized by headaches, altered mental status, seizures, and visual disturbances. It can occur in many different clinical entities such as severe hypertension and pre-eclampsia, or due to cytotoxic or immunosuppressive therapies. The pathogenesis of PRES is unclear, with dysregulated cerebral auto-regulation and endothelial dysfunction as important mechanisms proposed. Endothelial dysfunction is important especially in cases associated with cytotoxic therapies. Herein, we describe a patient with PRES with fatal outcome, who presented 5 days after the infusion of cycle 1 of irinotecan hydrochloride, leucovorin calcium, and fluorouracil (FOLFIRI) regimen chemotherapy, without prior hypertension and other comorbidity, suggesting a link between PRES and FOLFIRI regimen. To our knowledge, this case report is the first describing PRES after FOLFIRI regimen, although others have described PRES after FOLFIRI with bevacizumab in colonic cancer patients.
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Affiliation(s)
- Natalija Dedić Plavetić
- Department of Oncology, University Hospital Center, Kišpatićeva 12, HR-10000 Zagreb, Croatia.
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Wang W, Zhao LR, Lin XQ, Feng F. Reversible posterior leukoencephalopathy syndrome induced by bevacizumab plus chemotherapy in colorectal cancer. World J Gastroenterol 2014; 20:6691-6697. [PMID: 24914397 PMCID: PMC4047361 DOI: 10.3748/wjg.v20.i21.6691] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2013] [Accepted: 03/19/2014] [Indexed: 02/06/2023] Open
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare brain-capillary leak syndrome, characterized by clinical symptoms of headache, visual loss, seizures and altered mental functioning. This syndrome is usually reversible and is associated with hypertension, nephropathy, and use of immunosuppressive medication and cytotoxic agents. We describe two rare cases of RPLS occurring in colorectal cancer, both of which presented with coma, that we believe can be directly attributed to bevacizumab, a monoclonal antibody that inhibits the angiogenesis of tumours by specifically blocking vascular endothelial growth factor. We analysed the clinical features, risk factors and outcomes of RPLS in these two patients, and although no typical finding was identified on imaging examination, we found that inadequate blood pressure control was one of the risk factors leading to RPLS and that supportive treatment including intensive blood pressure control improved outcomes. Due to the increasing use of bevacizumab in colorectal cancer, clinicians should be aware of this potential complication.
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Abstract
Iatrogenic disease is one of the most frequent causes of hospital admissions and constitutes a growing public health problem. The most common type of iatrogenic neurologic disease is pharmacologic, and the central and peripheral nervous systems are particularly vulnerable. Despite this, iatrogenic disease is generally overlooked as a differential diagnosis among neurologic patients. The clinical picture of pharmacologically mediated iatrogenic neurologic disease can range from mild to fatal. Common and uncommon forms of drug toxicity are comprehensively addressed in this chapter. While the majority of neurologic adverse effects are listed and referenced in the tables, the most relevant issues are further discussed in the text.
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Affiliation(s)
- Luciano A Sposato
- Department of Clinical Neurological Sciences, London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | - Osvaldo Fustinoni
- INEBA Institute of Neurosciences, Buenos Aires, Argentina; Faculty of Medicine, University of Buenos Aires, Buenos Aires, Argentina.
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Yan R, Wu Q, Ren J, Cui H, Zhai K, Zhai Z, Duan Q. Clinical features and magnetic resonance image analysis of 15 cases of demyelinating leukoencephalopathy induced by levamisole. Exp Ther Med 2013. [PMID: 23935721 DOI: 10.3892/etm.2013.1077"] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The aim of this study was to explore the diagnostic value of magnetic resonance imaging (MRI) for levamisole-induced demyelinating leukoencephalopathy. The clinical features and MRI findings of 15 patients with levamisole-induced demyelinating leukoencephalopathy were retrospectively analyzed. The abnormality rate of the patients was demonstrated to be 100% by MRI, and scattered multiple cerebral foci were observed in all of the patients. The majority of the foci were located at the centrum ovale, peri-lateral cerebral ventricles and basal ganglia, while the remainder were located in the brain stem and cerebellum, as well as in the white matter regions of the temporal, frontal, apical and occipital lobes. In addition, mottling and ring-shaped enhancements were observed. The study demonstrated that MRI effectively displays demyelinating leukoencephalopathy, and that the combination of MRI with the medical history of the patient is of significance for the early diagnosis, differentiation and treatment of demyelinating leukoencephalopathy.
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Affiliation(s)
- Ruifang Yan
- Center of Medical Imaging, The First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan 453100
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Yan R, Wu Q, Ren J, Cui H, Zhai K, Zhai Z, Duan Q. Clinical features and magnetic resonance image analysis of 15 cases of demyelinating leukoencephalopathy induced by levamisole. Exp Ther Med 2013; 6:71-74. [PMID: 23935721 PMCID: PMC3735607 DOI: 10.3892/etm.2013.1077] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 04/09/2013] [Indexed: 11/25/2022] Open
Abstract
The aim of this study was to explore the diagnostic value of magnetic resonance imaging (MRI) for levamisole-induced demyelinating leukoencephalopathy. The clinical features and MRI findings of 15 patients with levamisole-induced demyelinating leukoencephalopathy were retrospectively analyzed. The abnormality rate of the patients was demonstrated to be 100% by MRI, and scattered multiple cerebral foci were observed in all of the patients. The majority of the foci were located at the centrum ovale, peri-lateral cerebral ventricles and basal ganglia, while the remainder were located in the brain stem and cerebellum, as well as in the white matter regions of the temporal, frontal, apical and occipital lobes. In addition, mottling and ring-shaped enhancements were observed. The study demonstrated that MRI effectively displays demyelinating leukoencephalopathy, and that the combination of MRI with the medical history of the patient is of significance for the early diagnosis, differentiation and treatment of demyelinating leukoencephalopathy.
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Affiliation(s)
- Ruifang Yan
- Center of Medical Imaging, The First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan 453100
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Shea JL. Bioanalytical methods for quantitation of levamisole, a widespread cocaine adulterant. Clin Chem Lab Med 2013; 51:205-12. [DOI: 10.1515/cclm-2012-0519] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 10/04/2012] [Indexed: 11/15/2022]
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Schwartzman AD, Sethi R, Smith R. Multiorgan failure in a patient treated with the 5-fluorouracil, leucovorin, oxaliplatin, and irinotecan regimen. Clin Colorectal Cancer 2012; 12:136-9. [PMID: 23098664 DOI: 10.1016/j.clcc.2012.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 08/20/2012] [Accepted: 09/13/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Andrew D Schwartzman
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Brookline, MA 02446, USA.
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Abstract
Neurologic dysfunction is a common side effect of many chemotherapy drugs. For several agents neurotoxicity is common, severe, and can be dose limiting. As the list of newer chemotherapy agents and systemic targeted therapies grows, so does the number and variety of potential neurotoxicities. This article reviews the clinical features of chemotherapy-induced syndromes involving the central and peripheral nervous systems.
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Reversible Leukoencephalopathy With Stroke-Like Presentation in a Patient With 5-Dihydropyrimidine Dehydrogenase Deficiency Treated With Continuous 5-Fluorouracil Infusion. Clin Colorectal Cancer 2012; 11:215-7. [DOI: 10.1016/j.clcc.2012.01.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 12/29/2011] [Accepted: 01/20/2012] [Indexed: 11/18/2022]
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Matsunaga M, Araki K, Miwa K, Sunakawa Y, Yamashita K, Narabayashi M, Noguchi T, Nagashima F, Sasaki Y. Reversible posterior leukoencephalopathy syndrome associated with mFOLFOX6 chemotherapy. Int Cancer Conf J 2012. [DOI: 10.1007/s13691-012-0033-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Larocque A, Hoffman RS. Levamisole in cocaine: unexpected news from an old acquaintance. Clin Toxicol (Phila) 2012; 50:231-41. [PMID: 22455354 DOI: 10.3109/15563650.2012.665455] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Levamisole is a pharmaceutical with anthelminthic and immunomodulatory properties that was previously used in both animals and humans to treat inflammatory conditions and cancer. Levamisole has been identified as a cocaine adulterant in the United States since 2003. By 2009, the United States Drug Enforcement Administration (DEA) estimated that 69% of the cocaine seized contained levamisole. The first case reports of complications related to levamisole in cocaine users were published in 2009. The objectives of this article are to review the literature regarding the full spectrum of possible complications related to levamisole use for medical purposes, to review the current scope of levamisole-induced complications in cocaine users and to discuss the pharmacological properties that might explain the motivation behind the large-scale adulteration of cocaine with levamisole. Literature review revealed that significant complications were quickly reported when levamisole was used in inflammatory conditions. By 1976, several cases of leukopenia and agranulocytosis were reported. Recurrence with re-exposure was well described and agranulocytosis spontaneously reversed upon discontinuation of therapy. Vasculitis secondary to levamisole treatment was first reported in 1978 and mostly manifests as leukocytoclastic vasculitis, cutaneous necrotising vasculitis and thrombotic vasculopathy without vasculitis. These findings typically, but not invariably, involve the ear lobes. Discontinuation of levamisole therapy was again a critical part of the treatment. Various neurological side effects were described with levamisole therapy, the most concerning complication being multifocal inflammatory leukoencephalopathy (MIL). Literature review identified 203 unique cases of complications in cocaine users that can be attributed to levamisole adulteration. The two principal complications reported are haematological (140 cases of neutropenia) and dermatological (84 cases). Even though these complications can occur in isolation, many cases displayed both simultaneously. No formal case of leukoencephalopathy in the setting of cocaine use has been reported so far. A striking phenomenon is the apparent high level of recurrence (27.1%) of symptoms in cocaine users after re-exposure to cocaine that is presumably adulterated. The importance of accurately identifying levamisole-induced complications is therefore critical for symptomatic patients as discontinuation of exposure is fundamental and as a correct diagnosis prevents unnecessary and potentially dangerous use of other treatment modalities like powerful immunosuppressive therapy. Literature review suggests that levamisole might have the advantages of enhancing noradrenergic neurotransmission by inhibiting reuptake, by inhibiting MAO and/or COMT, by acting on ganglionic nicotinic receptors and by being partially metabolized into an amphetamine-like compound. It could also increase endogenous opioids and increase dopamine concentration in the cerebral reward pathway. These potential effects make levamisole an interesting choice as a cocaine adulterant. It seems unlikely that levamisole use as a cocaine adulterant will soon reach an end. More information is needed about the diagnosis and treatment of levamisole-induced complications, and the efforts of the medical and public health community is needed to face this challenging problem.
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Affiliation(s)
- Alexandre Larocque
- Emergency Medicine Department, Centre Hospitalier de l'Université de Montréal, Clinical Toxicology Service, McGill University Health Center, Centre Antipoison du Québec, Montreal, Quebec, Canada.
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Rinne ML, Lee EQ, Wen PY. Central nervous system complications of cancer therapy. ACTA ACUST UNITED AC 2012; 10:133-41. [PMID: 22542045 DOI: 10.1016/j.suponc.2011.11.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Revised: 10/05/2011] [Accepted: 11/15/2011] [Indexed: 11/16/2022]
Abstract
As more effective therapies prolong the survival of patients with cancer, therapy-related toxicities, particularly those affecting the central nervous system (CNS) become increasingly important. CNS complications can cause significant morbidity and can limit the dose or duration of otherwise effective treatments. Because effects on the CNS are disabling and often permanent and treatments remain limited, it is important that clinicians recognize the effects of cancer therapy on the CNS. Cytotoxic chemotherapy and radiation are well-known causes of neurotoxicity, but there is increasing recognition that novel therapies are also sources of adverse effects on the CNS. This review highlights the CNS complications that result from radiation, chemotherapy, and novel therapeutics.
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Affiliation(s)
- Mikael L Rinne
- Center for Neuro-Oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave, Boston, MA 02215, USA
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Aberastury MN, Silva WH, Vaccarezza MM, Maxit C, Agosta G. Epilepsia partialis continua associated with levamisole. Pediatr Neurol 2011; 44:385-8. [PMID: 21481750 DOI: 10.1016/j.pediatrneurol.2010.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Revised: 08/31/2010] [Accepted: 11/29/2010] [Indexed: 11/24/2022]
Abstract
Epilepsia partialis continua is defined as a spontaneous regular or irregular clonic muscular twitching affecting a limited part of the body, occurring for a minimum of 1 hour and recurring at intervals of less than 10 seconds. Levamisole is used as an immunomodulating medication in patients with recurrent aphthous ulcers. Evidence suggests that it can induce multifocal inflammatory leukoencephalopathy. We describe the clinical neuroimaging and ictal electroencephalographic findings in an adolescent with epilepsia partialis continua caused by the administration of levamisole with cortical and subcortical lesions. To our knowledge, this is the first report that describes the association of epilepsia partialis continua cortical lesions detected by magnetic resonance imaging and levamisole that were not previously described.
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Affiliation(s)
- Marina N Aberastury
- Department of Pediatric Neurology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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Hernandez SH, Wiener SW, Smith SW. Case files of the New York City poison control center: paradichlorobenzene-induced leukoencephalopathy. J Med Toxicol 2010; 6:217-29. [PMID: 20373064 DOI: 10.1007/s13181-010-0053-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Dietrich J. Chemotherapy associated central nervous system damage. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2010; 678:77-85. [PMID: 20738009 DOI: 10.1007/978-1-4419-6306-2_11] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Chemotherapy is commonly associated with harmful effects to multiple organ systems, including the central nervous system (CNS). Neurotoxicity may manifest as both acute and delayed complications, which is particularly a concern for long-term survivors. Patients may experience a wide range of neurotoxic syndromes, ranging from neuro-vascular complications and focal neurological deficits to generalized neurological decline with cognitive impairment, cortical atrophy and white matter abnormalities. Along with the use of more aggressive and combined treatment modalities and prolonged survival of cancer patients, neurological complications have been observed with increasing frequency. The mechanisms by which cancer therapy, including chemotherapy and radiation, result in neurological complications, have been poorly understood. Recent studies have now started to unravel the cell-biological basis for commonly seen neurotoxic syndromes and have provided compelling explanations for delayed neurological complications, such as cognitive decline, progressive myelin disruption and brain atrophy.
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Affiliation(s)
- Jörg Dietrich
- Department of Neurology, MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street Yawkey 9E, Boston, Massachusetts 02114, USA.
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Xu N, Zhou W, Li S, Zhou G, Zhang N, Liang J. Clinical and MRI Characteristics of Levamisole-Induced Leukoencephalopathy in 16 Patients. J Neuroimaging 2009; 19:326-31. [DOI: 10.1111/j.1552-6569.2008.00344.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Ngeow JYY, Prakash KM, Chowbay B, Quek ST, Choo SP. Capecitabine-induced oromandibular dystonia: a case report and literature review. Acta Oncol 2009; 47:1161-5. [PMID: 18607849 DOI: 10.1080/02841860701721785] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Tipples K, Kolluri RB, Raouf S. Encephalopathy secondary to capecitabine chemotherapy: a case report and discussion. J Oncol Pharm Pract 2009; 15:237-9. [DOI: 10.1177/1078155209102511] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction. Capecitabine is an oral prodrug of 5-fluorouracil (5-FU) chemotherapy and is licenced for the treatment of breast and gastrointestinal cancers. Multifocal inflammatory leukoencephalopathy has been associated with intravenous 5-FU, but only a few cases of capecitabine-induced encephalopathy have been reported. Setting. We describe here a case of encephalopathy following administration of Epirubicin/ Cisplatin/Capecitabine chemotherapy, review those cases previously described and suggest recommendations for management. Results. Symptoms of neurotoxicity from 5-FU and capecitabine usually include confusion, ataxia, nystagmus, dysarthria, sensory loss, and memory loss. Withdrawal of the drug generally leads to improvement of symptoms and steroids are of only questionable benefit. Conclusion. Patients on fluouropyrimidine drugs with new neurological symptoms should be investigated with brain MRI scan and the drug should be withdrawn until symptoms resolve. Dihydropyrimidine dehydrogenase deficiency should be excluded and ideally an alternative chemotherapy regime sought. We would encourage reporting of such incidences to gain a clearer picture of the incidence and optimal management. J Oncol Pharm Practice (2009) 15: 237—239.
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Affiliation(s)
- Karen Tipples
- Oncology Department, Queen's Hospital, Rom Valley Way, Romford, Essex, RM7 0AG, UK,
| | - Rajeev B Kolluri
- Oncology Department, Queen's Hospital, Rom Valley Way, Romford, Essex, RM7 0AG, UK
| | - Sherif Raouf
- Oncology Department, Queen's Hospital, Rom Valley Way, Romford, Essex, RM7 0AG, UK
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Dietrich J, Monje M, Wefel J, Meyers C. Clinical patterns and biological correlates of cognitive dysfunction associated with cancer therapy. Oncologist 2008; 13:1285-95. [PMID: 19019972 DOI: 10.1634/theoncologist.2008-0130] [Citation(s) in RCA: 249] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Standard oncological therapies, such as chemotherapy and cranial radiotherapy, frequently result in a spectrum of neurocognitive deficits that includes impaired learning, memory, attention, and speed of information processing. In addition to classical mechanisms of neurotoxicity associated with chemo- and radiotherapy, such as radiation necrosis and leukoencephalopathy, damage to dynamic progenitor cell populations in the brain is emerging as an important etiologic factor. Radiation- and chemotherapy-induced damage to progenitor populations responsible for maintenance of white matter integrity and adult hippocampal neurogenesis is now believed to play a major role in the neurocognitive impairment many cancer survivors experience.
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Affiliation(s)
- Jörg Dietrich
- Department of Neurology, Division of Neuro-Oncology, Stephen E and Catherine Pappas Center for Neuro-Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Abstract
BACKGROUND Colon cancer is potentially curable by surgery. Although adjuvant chemotherapy benefits patients with stage III disease, there is uncertainty of such benefit in stage II colon cancer. A systematic review of the literature was performed to better define the potential benefits of adjuvant therapy for patients with stage II colon cancer. OBJECTIVES To determine the effects of adjuvant therapy on overall survival and disease-free survival in patients with stage II colon cancer. SEARCH STRATEGY Ovid MEDLINE (1986-2007), EMBASE (1980-2007), and EBM Reviews - Cochrane Central Register of Controlled Trials ( to 2007) were searched using the medical headings "colonic neoplasms", "colorectal neoplasms", "adjuvant chemotherapy", "adjuvant radiotherapy" and "immunotherapy", and the text words "colon cancer" and "colonic neoplasms". In addition, proceedings from the annual meetings of the American Society of Clinical Oncology and the European Society of Medical Oncology (1996 to 2004) as well as personal files were searched for additional information. SELECTION CRITERIA Randomized trials or meta-analyses containing data on stage II colon cancer patients undergoing adjuvant therapy versus surgery alone. DATA COLLECTION AND ANALYSIS :Three reviewers summarized the results of selected studies. The main outcomes of interest were overall and disease-free survival, however, data on toxicity and treatment delivery were also recorded. MAIN RESULTS With regards to the effect of adjuvant therapy on stage II colon cancer, the pooled relative risk ratio for overall survival was 0.96 (95% confidence interval 0.88, 1.05). With regards to disease-free survival, the pooled relative risk ratio was 0.83 (95% confidence interval 0.75, 0.92). AUTHORS' CONCLUSIONS Although there was no improvement in overall survival in the pooled analysis, we did find that disease-free survival in patients with stage II colon cancer was significantly better with the use of adjuvant therapy. It seems reasonable to discuss the benefits of adjuvant systemic chemotherapy with those stage II patients who have high risk features, including obstruction, perforation, inadequate lymph node sampling or T4 disease. The co-morbidities and likelihood of tolerating adjuvant systemic chemotherapy should be considered as well. There exists a need to further define which high-risk features in stage II colon cancer patients should be used to select patients for adjuvant therapy. Also, researchers must continue to search for other therapies which might be more effective, shorter in duration and less toxic than those available today.
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Affiliation(s)
- Alvaro Figueredo
- Hamilton Regional Cancer Centre, McMaster Univ., Dept. of Clin. Epid. and Stat.,, 699 Concession Street, Hamilton, Ontario, Canada, L8V 5C2.
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Han R, Yang YM, Dietrich J, Luebke A, Mayer-Pröschel M, Noble M. Systemic 5-fluorouracil treatment causes a syndrome of delayed myelin destruction in the central nervous system. J Biol 2008; 7:12. [PMID: 18430259 PMCID: PMC2397490 DOI: 10.1186/jbiol69] [Citation(s) in RCA: 217] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 01/03/2008] [Accepted: 02/19/2008] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Cancer treatment with a variety of chemotherapeutic agents often is associated with delayed adverse neurological consequences. Despite their clinical importance, almost nothing is known about the basis for such effects. It is not even known whether the occurrence of delayed adverse effects requires exposure to multiple chemotherapeutic agents, the presence of both chemotherapeutic agents and the body's own response to cancer, prolonged damage to the blood-brain barrier, inflammation or other such changes. Nor are there any animal models that could enable the study of this important problem. RESULTS We found that clinically relevant concentrations of 5-fluorouracil (5-FU; a widely used chemotherapeutic agent) were toxic for both central nervous system (CNS) progenitor cells and non-dividing oligodendrocytes in vitro and in vivo. Short-term systemic administration of 5-FU caused both acute CNS damage and a syndrome of progressively worsening delayed damage to myelinated tracts of the CNS associated with altered transcriptional regulation in oligodendrocytes and extensive myelin pathology. Functional analysis also provided the first demonstration of delayed effects of chemotherapy on the latency of impulse conduction in the auditory system, offering the possibility of non-invasive analysis of myelin damage associated with cancer treatment. CONCLUSIONS Our studies demonstrate that systemic treatment with a single chemotherapeutic agent, 5-FU, is sufficient to cause a syndrome of delayed CNS damage and provide the first animal model of delayed damage to white-matter tracts of individuals treated with systemic chemotherapy. Unlike that caused by local irradiation, the degeneration caused by 5-FU treatment did not correlate with either chronic inflammation or extensive vascular damage and appears to represent a new class of delayed degenerative damage in the CNS.
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Affiliation(s)
- Ruolan Han
- Department of Biomedical Genetics and University of Rochester Stem Cell and Regenerative Medicine Institute, University of Rochester Medical Center, Elmwood Avenue, Rochester, NY 14642, USA.
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Bradley K, Ian Robins H. Neurologic Complications of Therapy. Oncology 2007. [DOI: 10.1007/0-387-31056-8_79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Singh G, Rees JH, Sander JW. Seizures and epilepsy in oncological practice: causes, course, mechanisms and treatment. J Neurol Neurosurg Psychiatry 2007; 78:342-9. [PMID: 17369589 PMCID: PMC2077803 DOI: 10.1136/jnnp.2006.106211] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
There are few data available on the causes and mechanistic basis, outcome and treatment of seizures and epilepsy in people with systemic cancer. Seizures and epilepsy in people with cancers other than primary brain tumours are reviewed here. Articles published in English, which discussed the neurological manifestations and complications of cancer and its treatment, were searched and information on the frequency, aetiology, and course of seizures and epilepsy was extracted. The frequency, aetiology and outcome of seizure disorders in patients with cancer differ from those in the general population. Intracranial metastasis, cancer drugs and metabolic disturbances are the most common causes. Infections, cerebrovascular complications of systemic cancer and paraneoplastic disorders are among the rarer causes of seizures in patients with neoplasms. Several drugs used in the treatment of cancer, or complications arising from their use, can trigger seizures through varied mechanisms. Most drug-induced seizures are provoked and do not require long-term treatment with antiepileptic drugs.
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Affiliation(s)
- Gagandeep Singh
- Department of Neurology, Dayanand Medical College, Ludhiana, India
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Lin CH, Jeng JS, Hsieh ST, Yip PK, Wu RM. Acute disseminated encephalomyelitis: a follow-up study in Taiwan. J Neurol Neurosurg Psychiatry 2007; 78:162-7. [PMID: 17028121 PMCID: PMC2077670 DOI: 10.1136/jnnp.2005.084194] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Acute-disseminated encephalomyelitis (ADEM) is a demyelinating disorder of the central nervous system, whose epidemiology, clinical presentations and functional outcome are incompletely understood in Asian populations. OBJECTIVE To assess the clinical presentations, predisposing factors and functional outcome of ADEM in Taiwan. METHODS 50 patients initially diagnosed with ADEM (male, 19; female, 31) were enrolled from 1991 to 2005. Diagnosis of ADEM or multiple sclerosis was established during a follow-up period of 2-120 months. 8 adult patients were noted to have taken the immunomodulatory drug, levamisole, within 3 months before onset of symptoms. The remaining 42 patients (male, 17; female, 25) were categorised by age as children (<16 years, n = 12), young adults (16-49 years, n = 21) and elderly adults (> or =50 years, n = 9). The clinical manifestations, predisposing factors and radiological findings were compared between different age groups and adult patients with or without levamisole use. Functional outcome was compared by a log-rank test. RESULTS Preceding upper respiratory tract infection was evident in 21 (50%) patients and only one young-adult patient had received Rubella vaccine immunisation. The frequency of fever was higher in children (p = 0.04) and psychiatric symptoms were more prevalent in elderly patients (p = 0.03). Functional recovery was faster in children than in adults (p = 0.002). Initial Expanded Disability Status Scale score (odds ratio (OR) 1.9, p = 0.03) and no fever (OR 0.04, p = 0.06) were associated with poor outcome (modified Rankin scale > or =2). After a mean (SD) follow-up of 31.8 (9.9) months, 4 (9.5%) patients developed multiple sclerosis (3 (25%) children, 1 (4.7%) young adult, p = 0.03). The neurological disability, radiological and cerebrospinal fluid findings did not differ between patients with and without levamisole use. One elderly adult patient previously receiving levamisole developed multiple sclerosis of relapse-remitting type after a mean follow-up period of 36.9 months. CONCLUSION The clinical presentations, functional outcome and risk of developing multiple sclerosis differed between different age groups. Functional recovery was faster in children than in adults. Poor functional outcome was related to initial high Expanded Disability Status Scale score and absence of fever.
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Affiliation(s)
- C-H Lin
- Department of Neurology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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