A Multiphasic Presentation of Methotrexate Toxicity In a Pediatric Patient
Background:
Methotrexate neurotoxicity is associated with stroke-like symptoms such as aphasia, extremity weakness, ataxia and sensory deficits. These symptoms are known to rapidly disappear.
Design/Methods:
Review of the patient chart and the literature
Results:
11 year old female with B-ALL being treated with intrathecal Methotrexate who presented after experiencing stroke-like symptoms. Right upper extremity weakness and dysarthria were her only symptoms, both of which resolved within 15 minutes. She had complete symptom resolution prior to reaching the hospital where a code stroke was completed with a normal MRI and MRA of the brain. The next night the patient had further transient neurologic symptoms including right facial palsy, dysarthria, right upper extremity weakness and ataxia. The symptoms on this occasion lasted approximately 30 minutes but again resolved prior to reaching the hospital. On the second presentation she was monitored for 4 hours when acute neurologic symptoms re-emerged and an MRI of the brain was concomitantly obtained. The MRI showed a moderate sized area of restricted diffusion in the left MCA territory (left centrum ovale and corona radiata) with a small area of restricted diffusion in the right corona radiata and suboccipital white matter of the right occipital lobe. The patient was re-evaluated the morning after her abnormal MRI was obtained and her neurologic symptoms had once again resolved. On a follow up MRI brain obtained the day after her abnormal MRI, there was complete resolution of the previously exhibited multifocal areas of restricted diffusion.
Conclusions:
Methotrexate neurotoxicity is an established cause of stroke-like symptoms. It has not been well documented for Methotrexate neurotoxicity to cause such a multiphasic course of symptoms as in this patient. Methotrexate toxicity should be considered in all patients receiving intrathecal Methotrexate who present with stroke-like symptoms in both the presence or absence of restricted diffusion on a brain MRI.
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