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Myelopathy associated with intrathecal methotrexate.
Pedro Gustavo Barros Rodrigues1, Talles Tavares de Lima2, Fernando Barroso Duarte3,4
1Division of Neurology, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil gustavo.rodrigues675@hotmail.com.
Practical Neurology
|October 30, 2021
Summary
Intrathecal methotrexate can cause serious spinal cord toxicity, mimicking vitamin deficiencies. Promptly stopping chemotherapy and administering folate led to rapid recovery in a patient with acute lymphoblastic leukemia.
Area of Science:
- Neuroscience
- Oncology
- Hematology
Background:
- Intrathecal methotrexate is a chemotherapy agent used for central nervous system (CNS) leukemia treatment.
- Adverse neurological effects, including myelopathy, can occur following intrathecal methotrexate administration.
Observation:
- A 21-year-old male with acute lymphoblastic leukemia presented with progressive lower limb numbness, gait disturbance, and urinary incontinence.
- Magnetic Resonance (MR) imaging revealed significant spinal cord changes in the thoracic dorsal columns, consistent with myelopathy.
- The patient had received intrathecal methotrexate 20 days prior to symptom onset.
Findings:
- The patient's presentation and imaging findings mimicked subacute combined degeneration, often associated with vitamin B12 or folate deficiency.
- Serum folate levels were at the lower limit of normal.
- Discontinuation of intrathecal chemotherapy and administration of folate resulted in marked clinical improvement.
Implications:
- Intrathecal methotrexate-induced myelopathy is a critical diagnosis to consider in patients with neurological deficits after treatment.
- Exclusion of CNS leukemia infiltration is essential.
- Prompt management involving cessation of chemotherapy and supplementation of potential deficiencies (folate, vitamin B12) can reverse neurological damage.
