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Sohn JT. Dosage of Aminophylline Used for the Treatment of Neurotoxicity Caused by Methotrexate. Am J Ther 2023; 30:e390-e391. [PMID: 37449931 DOI: 10.1097/mjt.0000000000001444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ju-Tae Sohn
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University College of Medicine, Gyeongsang National University Hospital, Jinju-si, Republic of Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju-si, Republic of Korea
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AlKawi A, Hanbali A, Haj Aissa N, Mufti MA, Abdul Rab S. Recurrence of methotrexate-induced leukoencephalopathy after methotrexate rechallenge: A case report and literature review. Radiol Case Rep 2023; 18:799-804. [PMID: 36582751 DOI: 10.1016/j.radcr.2022.11.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/16/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
Methotrexate (MTX) is potent chemotherapeutic agent, often administered intrathecally to treat or prevent central nervous system involvement in lymphomas and leukemias, particularly T-cell lymphoblastic leukemia (T-LBL). MTX has been linked to adverse neurologic effects that mimic acute stroke, including facial drooping, hemiplegia, impaired consciousness, and seizures, as well as changes on imaging-known as MTX-induced leukoencephalopathy (LE). We report a case of a 17-year-old male diagnosed with T-LBL, who had been receiving MTX chemotherapy for 4 months. After receiving his fourth dose of MTX, he presented to the emergency department with fever, facial drooping, and acute left-sided weakness. Brain magnetic resonance imaging (MRI) revealed bilateral deep white matter T2 hyperintense foci, increased on the right, with associated diffusion restriction in the right centrum semiovale-consistent with MTX-induced LE. After his symptoms resolved, he was discharged on leucovorin. Six months afterward, he was rechallenged with MTX and developed recurrence of symptoms. Repeat MRI showed well-defined T2/FLAIR hyperintensities in the right centrum semiovale without corresponding diffusion restriction. The left centrum semiovale hyperintensity became less conspicuous in comparison to the previous MRI study. We report a rare case of recurrence of LE after MTX rechallenge and discuss mechanisms, best imaging modalities, and possible treatment options for MTX-induced LE. Given the ominous presentation of MTX-induced LE, we urge clinicians to maintain a high index of suspicion for this condition. Further research is necessary to understand why only certain patients develop recurrence of LE after subsequent doses of MTX.
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Santangelo A, Bartolini E, Nuzzi G, Foiadelli T, Michev A, Mina T, Trambusti I, Fichera V, Bonuccelli A, Massimetti G, Peroni DG, De Marco E, Coccoli L, Luti L, Bernasconi S, Nardi M, Menconi MC, Casazza G, Pruna D, Mura R, Marra C, Zama D, Striano P, Cordelli DM, Battini R, Orsini A. The Clinical Impact of Methotrexate-Induced Stroke-Like Neurotoxicity in Paediatric Departments: An Italian Multi-Centre Case-Series. Front Neurol 2022; 13:920214. [PMID: 35756920 PMCID: PMC9226576 DOI: 10.3389/fneur.2022.920214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Stroke-like syndrome (SLS) is a rare subacute neurological complication of intrathecal or high-dose (≥500 mg) Methotrexate (MTX) administration. Its clinical features, evoking acute cerebral ischaemia with fluctuating course symptoms and a possible spontaneous resolution, have elicited interest among the scientific community. However, many issues are still open on the underlying pathogenesis, clinical, and therapeutic management and long-term outcome. Materials and Methods We retrospectively analyzed clinical, radiological and laboratory records of all patients diagnosed with SLS between 2011 and 2021 at 4 National referral centers for Pediatric Onco-Hematology. Patients with a latency period that was longer than 3 weeks between the last MTX administration of MTX and SLS onset were excluded from the analysis, as were those with unclear etiologies. We assessed symptom severity using a dedicated arbitrary scoring system. Eleven patients were included in the study. Results The underlying disease was acute lymphoblastic leukemia type B in 10/11 patients, while fibroblastic osteosarcoma was present in a single subject. The median age at diagnosis was 11 years (range 4-34), and 64% of the patients were women. Symptoms occurred after a mean of 9.45 days (± 0.75) since the last MTX administration and lasted between 1 and 96 h. Clinical features included hemiplegia and/or cranial nerves palsy, paraesthesia, movement or speech disorders, and seizure. All patients underwent neuroimaging studies (CT and/or MRI) and EEG. The scoring system revealed an average of 4.9 points (± 2.3), with a median of 5 points (maximum 20 points). We detected a linear correlation between the severity of the disease and age in male patients. Conclusions SLS is a rare, well-characterized complication of MTX administration. Despite the small sample, we have been able to confirm some of the previous findings in literature. We also identified a linear correlation between age and severity of the disease, which could improve the future clinical management.
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Affiliation(s)
- Andrea Santangelo
- Paediatric Neurology, Paediatric Department, Santa Chiara University Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Emanuele Bartolini
- Department of Developmental Neuroscience, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Fondazione Stella Maris, Pisa, Italy
| | - Giulia Nuzzi
- Paediatric Neurology, Paediatric Department, Santa Chiara University Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Thomas Foiadelli
- Clinica Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alexandre Michev
- Clinica Pediatrica, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Tommaso Mina
- Paediatric Haematology/Oncology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Irene Trambusti
- Paediatric Neurology, Paediatric Department, Santa Chiara University Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Valeria Fichera
- Paediatric Neurology, Paediatric Department, Santa Chiara University Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Alice Bonuccelli
- Paediatric Neurology, Paediatric Department, Santa Chiara University Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Gabriele Massimetti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Diego G Peroni
- Paediatric Neurology, Paediatric Department, Santa Chiara University Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Emanuela De Marco
- Paediatric Oncology and Haematology Department, Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Luca Coccoli
- Paediatric Oncology and Haematology Department, Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Laura Luti
- Paediatric Oncology and Haematology Department, Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Sayla Bernasconi
- Paediatric Oncology and Haematology Department, Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Margherita Nardi
- Paediatric Oncology and Haematology Department, Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Maria Cristina Menconi
- Paediatric Oncology and Haematology Department, Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Gabriella Casazza
- Paediatric Oncology and Haematology Department, Santa Chiara Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Dario Pruna
- Paediatric Neurology, Paediatric Department, ARNAS G. Brotzu, Cagliari, Italy
| | - Rosamaria Mura
- Paediatric Oncology and Haematology, Pediatric Department, ARNAS G. Brotzu, Cagliari, Italy
| | - Chiara Marra
- Paediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniele Zama
- Paediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Pasquale Striano
- Paediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova, Italy
| | - Duccio M Cordelli
- Unitá Operativa Complessa (UOC) Neuropsichiatria dell'età Pediatrica, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Roberta Battini
- Department of Developmental Neuroscience, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Fondazione Stella Maris, Pisa, Italy.,Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Orsini
- Paediatric Neurology, Paediatric Department, Santa Chiara University Hospital, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
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Peled Y, Levin D, Shiran S, Manisterski M, Shukrun R, Elhasid R. Prevalence and management of methotrexate-induced neurotoxicity in pediatric patients with osteosarcoma: a single-center experience. Int J Clin Oncol 2022; 27:1372-1378. [PMID: 35639227 DOI: 10.1007/s10147-022-02184-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/27/2022] [Indexed: 11/05/2022]
Abstract
AIMS To determine the incidence, clinical presentation, and outcome of methotrexate (MTX) associated neurotoxicity in pediatric patients treated for osteosarcoma, with the aim of identifying possible risk factors and suggesting recommended treatment for these sequelae. MATERIALS AND METHODS All medical files of patients treated for osteosarcoma in a single pediatric haemato-oncology center between November 2011 and August 2021 were retrospectively reviewed. All patients were treated according to the EURAMOS AOST0331 protocol, using cisplatin, doxorubicin, and high-dose MTX at a dose of 12 g/m2 over 4 h. RESULTS Seventy-eight patients with osteosarcoma were identified (age range 5 to 23 years, 42 males). Seven patients (9%) sustained neurotoxicity following treatment with high-dose MTX. Manifestations of neurotoxicity included among others, generalized seizures, confusion, encephalopathy, dysarthria, and choreiform movements. All but one episode occurred following two sequential cycles of high-dose MTX. All 7 had subacute toxicity, 5-10 days following MTX administration, and 1 had both acute and subacute toxicity. Brain MRI was performed for all patients and demonstrated typical MRI changes attributed to MTX neurotoxicity in 4 of them. Two patients received aminophylline; one patient received dextromethorphan. Patients with normal MRI imaging resumed MTX therapy without any sequels. No risk factors were found for high-dose MTX-related toxicity occurrence. CONCLUSIONS The time of risk of neurotoxicity due to high-dose MTX treatment for osteosarcoma is days 5-10 following two sequential treatment cycles. These findings together with treatment options for these adverse effects should be detailed in the therapeutic protocol of MTX use among pediatric patients with osteosarcoma.
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Affiliation(s)
- Yair Peled
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Levin
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shelly Shiran
- Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Michal Manisterski
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Shukrun
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel.,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Elhasid
- Department of Pediatric Hemato-Oncology, Dana Children's Hospital, Tel Aviv Medical Center, 6 Weizmann St, 6423906, Tel Aviv, Israel. .,Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Rubin MF, Kuhn AK. Management of methotrexate-induced neurotoxicity with aminophylline plus dextromethorphan in a pediatric patient with pineoblastoma. Pediatr Blood Cancer 2020; 67:e28515. [PMID: 32710710 DOI: 10.1002/pbc.28515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Mara Faye Rubin
- Department of Pharmacy, Nationwide Children's Hospital, Columbus, Ohio
| | - Alexis K Kuhn
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota
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Cruz-Carreras MT, Chaftari P, Shamsnia A, Guha-Thakurta N, Gonzalez C. Methotrexate-induced leukoencephalopathy presenting as stroke in the emergency department. Clin Case Rep 2017; 5:1644-1648. [PMID: 29026563 PMCID: PMC5628205 DOI: 10.1002/ccr3.1110] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 04/05/2017] [Accepted: 04/11/2017] [Indexed: 11/10/2022] Open
Abstract
Methotrexate-induced leukoencephalopathy is to be considered as a potential etiology in any patient presenting with stroke-like symptoms after receiving methotrexate. One of our cases suggests that the method of administration of the methotrexate can be IV or intrathecal and still results in leukoencephalopathy.
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Affiliation(s)
| | - Patrick Chaftari
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas
| | - Anna Shamsnia
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas
| | - Nandita Guha-Thakurta
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas
| | - Carmen Gonzalez
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas
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Giordano L, Akinyede O, Bhatt N, Dighe D, Iqbal A. Methotrexate-Induced Neurotoxicity in Hispanic Adolescents with High-Risk Acute Leukemia—A Case Series. J Adolesc Young Adult Oncol 2017; 6:494-498. [DOI: 10.1089/jayao.2016.0094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Lisa Giordano
- Department of Pediatrics, Cook County Health and Hospitals System, Chicago, Illinois
| | - Oyinade Akinyede
- Department of Pediatrics, Cook County Health and Hospitals System, Chicago, Illinois
| | - Nidhi Bhatt
- Department of Pediatrics, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Dipti Dighe
- Department of Pediatrics, Cook County Health and Hospitals System, Chicago, Illinois
| | - Asneha Iqbal
- Department of Pediatrics, Cook County Health and Hospitals System, Chicago, Illinois
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9
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Tzachanis D, Haider M, Papazisis G. A Case of Subacute Encephalopathy Developing After Treatment With Clofarabine and Methotrexate That Resolved With Corticosteroids. Am J Ther 2016; 23:e937-40. [PMID: 24987945 DOI: 10.1097/MJT.0000000000000091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This is the case of a 24-year-old woman with relapsed acute undifferentiated leukemia who developed subacute encephalopathy with hemiparesis and dysarthria after treatment with high dose and intrathecal methotrexate, clofarabine, and cytarabine that resolved rapidly and completely after the administration of corticosteroids. We hypothesize that clofarabine might predispose to methotrexate-induced central nervous system toxicity by increasing endothelial permeability (capillary leak syndrome) and suggest that corticosteroids are effective in the treatment of this type of encephalopathy.
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Rimkus CDM, Andrade CS, Leite CDC, McKinney AM, Lucato LT. Toxic leukoencephalopathies, including drug, medication, environmental, and radiation-induced encephalopathic syndromes. Semin Ultrasound CT MR 2014; 35:97-117. [PMID: 24745887 DOI: 10.1053/j.sult.2013.09.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Toxic leukoencephalopathies can be secondary to the exposure to a wide variety of exogenous agents, including cranial irradiation, chemotherapy, antiepileptic agents, drugs of abuse, and environmental toxins. There is no typical clinical picture, and patients can present with a wide array of signs and symptoms. Involvement of white matter is a key finding in this scenario, although in some circumstances other high metabolic areas of the central nervous system can also be affected. Magnetic resonance (MR) imaging usually discloses bilateral and symmetric white matter areas of hyperintense signal on T2-weighted and fluid-attenuated inversion recovery images, and signs of restricted diffusion are associated in the acute stage. In most cases, the changes are reversible, especially with prompt recognition of the disease and discontinuation of the noxious agent. Either the MR or clinical features may be similar to several nontoxic entities, such as demyelinating diseases, leukodystrophies, hepatic encephalopathy, vascular disease, hypoxic-ischemic states, and others. A high index of suspicion should be maintained whenever a patient presents recent onset of neurologic deficit, searching the risk of exposure to a neurotoxic agent. Getting to know the most frequent MR appearances and mechanisms of action of causative agents may help to make an early diagnosis and begin therapy, improving outcome. In this review, some of the most important causes of leukoencephalopathies are presented; as well as other 2 related conditions: strokelike migraine attacks after radiation therapy syndrome and reversible splenial lesions.
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Affiliation(s)
| | - Celi Santos Andrade
- Department of Radiology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Claudia da Costa Leite
- Department of Radiology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Alexander M McKinney
- Department of Radiology/Neuroradiology, University of Minnesota and Hennepin County Medical Centers, Minneapolis, MN
| | - Leandro Tavares Lucato
- Department of Radiology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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de Broucker T, Leclercq D, Jarquin S, Henry C. Acute leukoencephalopathy due to pyrimethamine. An insight into methotrexate neurotoxicity? J Neurol Sci 2013; 335:201-3. [PMID: 24157308 DOI: 10.1016/j.jns.2013.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 09/22/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
A unique case of pyrimethamine-related stroke-like leukoencephalopathy is described. The imputability of the drug is discussed as well as the similarities with the well-known methotrexate neurotoxicity. Owing to the same mode of action of both drugs by inhibition of the enzyme dihydrofolate reductase, this case is highly suggestive of the pathogenetic role of methylation pathway blockade on myelin synthesis resulting in delayed demyelination. This complication could be avoided by a concurrent folinic acid supplementation.
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Affiliation(s)
- Thomas de Broucker
- Service de Neurologie, Hôpital Delafontaine, 2, rue du Dr Delafontaine, 93200 Saint-Denis, France.
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12
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Abstract
Bipolar affective disorder is characterized by recurring episodes of mania with or without, but commonly with, episodes of depression. It usually begins in adolescence and can cause enduring and substantial impairment if left untreated. It needs a long-term treatment with mood stabilizers to prevent relapses. Elevated or depressed mood relapses can be either primary or secondary. However, primary mood relapses can occur without a significant precipitating factor, more often tending to occur following stressful life events or discontinuation of mood stabilizer medications. Secondary mood relapses can be caused by many conditions, such as physical illnesses, substance misuse and medications. When a mental illness coexists with another physical illness and the treatment of one complicates the other, it adds complexity to the selection of appropriate pharmacological regime for either condition. In this paper, the authors present a case of bipolar affective disorder who had two episodes of mania likely precipitated by methotrexate, which were reversed by the withdrawal of the offending drug (methotrexate). To the best of the authors' knowledge, to date there have been no published reports in the literature in which methotrexate, an immunosuppressive and a cytotoxic drug, precipitated a manic episode in a patient with bipolar affective disorder.
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Abstract
Over the last few decades, cure rates for pediatric cancer have increased dramatically, and now over 80 % of children with cancer are cured of their disease. This improvement in cure has come with a significant cost, with many children suffering irreversible, life-threatening, or long-lasting toxicities due to the medications required during their treatment. In the last 2 decades, major technological advances in genomics and the mapping of the human genome have made it possible to identify genetic differences between children in order to investigate differing responses to cancer therapy and to help explain why children treated with the same medications can have different outcomes. The emerging field of pharmacogenomics has had many important findings in pediatric cancer. The focus of this review is drug toxicity in pediatric cancer and the use of pharmacogenomics to reduce these adverse drug reactions, with a specific focus on thiopurines, methotrexate, cisplatin, vincristine and anthracyclines. Future areas of research and the need for international collaboration are discussed.
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Affiliation(s)
- Shahrad Rod Rassekh
- Department of Pediatrics, Division of Pediatric Hematology/Oncology/BMT, University of British Columbia, Vancouver, BC, Canada.
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Tufekci O, Yilmaz S, Karapinar TH, Gozmen S, Cakmakci H, Hiz S, Irken G, Oren H. A rare complication of intrathecal methotrexate in a child with acute lymphoblastic leukemia. Pediatr Hematol Oncol 2011; 28:517-22. [PMID: 21699468 DOI: 10.3109/08880018.2011.563773] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Methotrexate (MTX) is an essential component of chemotherapy for childhood acute lymphoblastic leukemia (ALL). Both intravenous and most commonly intrathecal routes of MTX have been implicated in acute, subacute, and chronic neurotoxicity syndromes. Subacute MTX neurotoxicity occurs within days to weeks after the intravenous or intrathecal therapy and characterized by a distinct presentation with remarkable clinical resemblance to stroke, including hemiparesis, hemisensory deficits, aphasia, dysarthria, dysphagia, and diplopia. Herein the authors describe the clinical and typical neuroimaging features of a female patient with ALL who presented with subacute MTX neurotoxicity that rapidly progressed to a severe clinical condition in a few hours but eventually resolved completely with dexamethasone and folinic acid. Subacute MTX neurotoxicity is a transient neurological dysfunction that should be considered in patients presenting with stroke-like and various neurological symptoms 10 to 14 days after intrathecal therapy and diffusion-weighted magnetic resonance imaging should be undertaken for the correct diagnosis and exclusion of possible ischemic infarct. Discontinuation of subsequent intrathecal MTX therapies should be considered in severe cases and treatment with dexamethasone and folinic acid may help to resolve the symptoms.
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Affiliation(s)
- Ozlem Tufekci
- Department of Pediatric Hematology, Dokuz Eylul University, Izmir, Turkey.
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15
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Bota DA, Dafer RM. Acute Methotrexate Neurotoxicity with Choreiform Movements and Focal Neurological Deficits: A Case Report: . South Med J 2009; 102:1071-4. [DOI: 10.1097/smj.0b013e3181b66b28] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Sioka C, Kyritsis AP. Central and peripheral nervous system toxicity of common chemotherapeutic agents. Cancer Chemother Pharmacol. 2009;63:761-767. [PMID: 19034447 DOI: 10.1007/s00280-008-0876-6] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 11/10/2008] [Indexed: 12/18/2022]
Abstract
Central and peripheral nervous system toxicity are frequent complications of most chemotherapy regimens, often leading to reduction of dosages or cessation of the responsible drugs. However, sometimes the afflicted toxicity may not be reversible, especially if it is not recognized early, further compromising the quality of life of the cancer patients. The most common chemotherapeutic agents that might cause CNS toxicity manifested as encephalopathy of various severities include methotrexate, vincristine, ifosfamide, cyclosporine, fludarabine, cytarabine, 5-fluorouracil, cisplatin and the interferons (alpha > beta). Involvement of the peripheral nervous system manifested as distal peripheral neuropathy results after therapy with cisplatin, vincristine, taxanes, suramin and thalidomide. Although several compounds have been proposed as neuroprotective agents, few have been shown to be active against the chemotherapy induced neurotoxicity.
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Bessell EM, Hoang-Xuan K, Ferreri AJM, Reni M. Primary central nervous system lymphoma: biological aspects and controversies in management. Eur J Cancer 2007; 43:1141-52. [PMID: 17433666 DOI: 10.1016/j.ejca.2006.12.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2006] [Accepted: 12/14/2006] [Indexed: 01/27/2023]
Abstract
INTRODUCTION This review was produced from the workshop on primary central nervous system lymphoma (PCNSL) at the European Cancer Conference (ECCO 13) in Paris in 2005. It covers the presentation and biological features of the disease (Professor Khe Hoang-Xuan). The role of chemotherapy, including the management of intraocular lymphoma and the use of high dose chemotherapy followed by autologous stem cell transplantation for PCNSL, is discussed (Dr. Andres Ferreri) as well as controversies in the use of whole brain radiotherapy (WBRT) after chemotherapy (Dr. Michele Reni). The topics covered with discussants at the workshop are also summarised. CONCLUSION The imaging of the brain and the histopathology including detailed immunohistochemistry is of vital importance in making an accurate diagnosis of the disease and understanding the extent of spread of the disease in the CNS. The importance of high dose methotrexate (HDMTX; dose > or = 1g/m(2)), as the most active drug in the treatment of PCNSL, is stressed. The authors recommend that HDMTX alone or in combination with other active chemotherapy agents should be used to treat PCNSL followed by whole brain radiotherapy (WBRT) unless contraindicated because of the advanced age of the patient and existing cognitive impairment. Only published protocols should be used unless the patient is to be offered a trial that has either national or international support. Baseline neuropsychological tests should be carried out before treatment and repeated during and after treatment. The risks of cognitive impairment associated with the disease, with methotrexate - containing chemotherapy and with whole brain radiotherapy should be explained to patients and relatives when obtaining informed consent. Long-term survival, with current treatment regimes, is possible with PCNSL but this appears limited to patients less than 60 years of age at presentation (mostly patients less than 50 years of age).
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Affiliation(s)
- Eric M Bessell
- Department of Clinical Oncology, Nottingham City Hospital, Hucknall Road, Nottingham, UK.
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Haykin ME, Gorman M, van Hoff J, Fulbright RK, Baehring JM. Diffusion-weighted MRI correlates of subacute methotrexate-related neurotoxicity. J Neurooncol 2006; 76:153-7. [PMID: 16411025 DOI: 10.1007/s11060-005-9569-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
OBJECTIVES A delayed stroke-like leukoencephalopathy has been observed in patients receiving methotrexate (MTX) for childhood leukemia. Diffusion-weighted MRI (DWI) may help to distinguish between ischemic stroke and chemotherapy-related leukoencephalopathy. Although conventional MRI correlates have been described for this stroke-like syndrome, DWI data are largely unavailable. Our objective is to present a retrospective analysis of the DWI findings in four patients who suffered subacute neurotoxicity after intrathecal MTX. DESIGN We reviewed the medical records of four patients, who were seen by us between July 2000 and February 2004 for sudden onset of a central neurological syndrome within days of intrathecal MTX. Patients underwent standardized MRI within 48 h of symptom onset; MRI included DWI and apparent diffusion coefficient (ADC) maps. RESULTS DWI of all patients revealed well-demarcated hyperintense lesions within the subcortical white matter corresponding to areas of restricted proton diffusion on ADC maps. Lesions exceeded the confines of adjacent vascular territories. Complete resolution of symptoms within 1-4 days was accompanied by normalization of ADC abnormalities. CONCLUSIONS DWI findings in this cohort seem to reflect cytotoxic edema within cerebral white matter suggesting a reversible metabolic derangement, rather than ischemia, as the basis for this syndrome.
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Affiliation(s)
- M E Haykin
- Department of Neurology, Yale University School of Medicine, TMP 410, New Haven, CT 06510, USA
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Abstract
OBJECTIVES A delayed stroke-like leukoencephalopathy has been observed in patients receiving methotrexate (MTX) for childhood leukemia. Diffusion-weighted MRI (DWI) may help to distinguish between ischemic stroke and chemotherapy-related leukoencephalopathy. Although conventional MRI correlates have been described for this stroke-like syndrome, DWI data are largely unavailable. Our objective is to present a retrospective analysis of the DWI findings in four patients who suffered subacute neurotoxicity after intrathecal MTX. DESIGN We reviewed the medical records of four patients, who were seen by us between July 2000 and February 2004 for sudden onset of a central neurological syndrome within days of intrathecal MTX. Patients underwent standardized MRI within 48 h of symptom onset; MRI included DWI and apparent diffusion coefficient (ADC) maps. RESULTS DWI of all patients revealed well-demarcated hyperintense lesions within the subcortical white matter corresponding to areas of restricted proton diffusion on ADC maps. Lesions exceeded the confines of adjacent vascular territories. Complete resolution of symptoms within 1-4 days was accompanied by normalization of ADC abnormalities. CONCLUSIONS DWI findings in this cohort seem to reflect cytotoxic edema within cerebral white matter suggesting a reversible metabolic derangement, rather than ischemia, as the basis for this syndrome.
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Affiliation(s)
- Me Haykin
- Department of Neurology, Yale University School of Medicine, TMP 410, New Haven, CT 06510, USA
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Abstract
Most children diagnosed today with acute lymphoblastic leukemia (ALL) will be cured. However, treatment entails risk of neurotoxicity, causing deficits in neurocognitive function that can persist in the years after treatment is completed. Many of the components of leukemia therapy can contribute to adverse neurologic sequelae, including craniospinal irradiation, nucleoside analogs, corticosteroids, and antifolates. In this review, we describe the characteristic radiographic findings and neurocognitive deficits seen among survivors of childhood ALL. We summarize what is known about the pathophysiology of delayed treatment-related neurotoxicity, with a focus on the toxicity resulting from pharmacologic disruption of folate physiology within the central nervous system. Finally, we suggest testable strategies to ameliorate the symptoms of treatment-related neurotoxicity or decrease its incidence.
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Affiliation(s)
- Peter D Cole
- Department of Pediatrics and Pharmacology, Robert Wood Johnson Medical School/UMDNJ, The Cancer Institute of New Jersey, New Brunswick, New Jersey 08901, USA.
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