Intracerebral (parenchymal) infusion of methotrexate: report of a case

This report describes the neuropathological findings in a 32 year old woman with acute myelogenous leukemia (AML) and central nervous system (CNS) involvement, who received a total of 48 mg of methotrexate (MTX) intended to be delivered to the ventricle. At autopsy, the tip of the infusion catheter was found to have been inadvertently placed in the left basal ganglia. The delivery of the MTX at that site caused white matter lesions characteristic of those previously reported in MTX encephalopathy following diverse modes of administration. This case is unusual in that there was the direct infusion of MTX into cerebral parenchyma, circumventing both the blood:brain and cerebrospinal fluid:brain barriers. Axonal abnormalities were widespread in the MTX-infused tissue, frequently but not always accompanied by myelin loss. Since radiation therapy had not been employed, this case permitted the assessment of pathologic changes largely attributable to MTX.