Progressive Neurotoxicity after Intrathecal Methotrexate and Cytarabine in a Child with Acute Myeloid Leukemia

Arushi Gahlot Saini, Jitendra Kumar Sahu, Sonali Mahapatra, Deepak Bansal, Paramjeet Singh, Pratibha Singhi

Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

^*Correspondance to: Pratibha Singhi 

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Abstract:

Background: Progressive encephalomyelitis with fatal course is an uncommon complication of intrathecal chemotherapy in children with acute myeloid leukemia.Aims: We describe the clinical and radiological spectrum of progressive neurotoxicity after combined intrathecal use of methotrexate and cytarabine in a child with acute myeloid leukemia.Methods: A 10-year-old boy suffering from acute myeloid leukemia developed acute-onset, progressive ascending myelitis followed by encephalopathy after triple intrathecal chemotherapy. He underwent detailed neurological assessments and relevant laboratory and radiological investigations. Intravenous antimicrobials, methyl prednisolone pulse therapy and megavitamins were administered.Results: Examination showed high-frequency horizontal nystagmus, diffuse meningismus, bilaterally symmetrical paraplegia, hypotonia, areflexia and flexor Babinski response in the lower limbs, saddle anaesthesia and urinary retention. Cerebrospinal fluid analysis showed 400 cells (95% polymorphonuclear cells, no blasts). Magnetic resonance imaging of spine showed long-tract myelitis with caudal nerve-root enhancement. Nerve-conduction study showed severe sensorymotor polyneuropathy involving lower limbs. The clinical course evolved from an acute, reversible chemical arachnoiditis to cauda-equina syndrome to a progressive, treatment-refractory, devastating encephalomyelitis over three weeks. He finally succumbed to nosocomial sepsis and cardiac arrest.Conclusion: Progressive neurotoxicity following intrathecal chemotherapy, especially with combination of methotrexate and cytarabine needs consideration in pediatric patients of leukemia. Early identification of evolving neurological signs may help in the initiation of early salvage therapy

Keywords:

Neurotoxicity; Intrathecal; Methotrexate; Cytarabine; Cauda-Equina; Encephalomyelitis

Cite the Article:

Saini AG, Sahu JK, Mahapatra S, Bansal D, Singh P, Singhi P. Progressive Neurotoxicity after Intrathecal Methotrexate and Cytarabine in a Child with Acute Myeloid Leukemia. Clin Oncol. 2018; 3: 1392.