Abstract Ref Number = APCP1098
CHRONIC ENCEPHALOPATHY DUE TO METHOTREXATE NEUROTOXICIY AS A RARE COMPLICATION IN A CHILD WITH LEUKEMIA A CASE REPORT
Achmad Rafli,Setyo Handryastuti,Ludi Dhyani Rahmartani,Srisadono Fauzi Adiprabowo
Department of Child Health Faculty of Medicine University Indonesia Ciptomangunkusumo General Hospital Jakarta Indonesia Neurology Division Department of Child Health, Faculty of MedicineUniversitas Indonesia Cipto Mangunkusumo General Hospital Jakarta Indonesia Hematology Oncology Division Department of Child Health, Faculty of MedicineUniversitas Indonesia Cipto Mangunkusumo General Hospital Jakarta Indonesia Department of Child Health, Faculty of MedicineUniversitas Indonesia Cipto Mangunkusumo General Hospital Jakarta Indonesia
Background : Methotrexate (MTX) is an essential component of chemotherapy for childhood acute lymphoblastic leukemia (ALL). Although it has dose-limiting hematologic and mucocutaneous toxicities, neurotoxicity caused by MTX is clinically the most important adverse effect. It may be transient and reversible but severe neurological disorders leading to coma or even death may occur as well. Both intravenous (IV) and most commonly intrathecal (IT) routes of MTX have been complicated in acute, subacute, and chronic neurotoxicity syndromes.
Case Presentation Summary : A 9-year-old girl presented with episodes loss of consciousness since 3 months before hospital admission. She has diagnosed with acute lymphoblastic leukemia relapse since 2015. The last chemotherapy protocol of patient was Indonesian Protocol Acute Lymphoblastic Leukemia (ALL) 2013 maintenance-high risk (IT MTX 84 mg and oral MTX 1000 mg/m2). Previously, it was thought that the cause of persisting of consciousness was infiltration or intracranial bleeding and computed tomography (CT-Scan) of the brain was performed and showed brain atrophy with no pathological lesion/hemorrhage/space occupying lesion. It is correlated with magnetic resonance imaging (MRI) of the brain that revealed brain atrophy that it can be in accordance with chronic encephalopathy due to MTX. One month later, she had abnormality in functional and behavioral ability. The patient’s total dosage of MTX was 336 mg (IT), 6000 mg/m2 (IV), and 2500 mg/m2 orally. Immediate CT-Scan of the brain revealed brain atrophy, lacunar infarct in left pons, with no hemorrhage.
Learning Points/Discussion : It is important to recognize early and distant complications taking the form of subclinical or symptomatic CNS damage (e.g. headache, dizziness, tremor, ataxia, aphasia, dysarthria, emotional instabilities, seizures, hemiparesis, encephalopathy) that can occur in the course of chemotherapy especially MTX. Determination of the cause of encephalopathy is associated with considerable difficulty despite the use of various diagnostic methods and also treatment of MTX neurotoxicity is mainly supportive and recovery is usually complete.
Keywords: imaging methotrexate neurotoxicity leukemia