Methotrexate-induced neurotoxicity: Diagnostic challenges and the role of neurophysiological testing

IF 2 Q3 NEUROSCIENCES

Clinical Neurophysiology Practice Pub Date : 2025-01-01 DOI:10.1016/j.cnp.2025.06.004

Pauline D’hoore , Joke Terryn

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引用次数: 0

Abstract

Methotrexate (MTX) is widely used in the treatment of acute lymphocytic leukemia (ALL) and other onco-hematological conditions. Although subacute MTX-related neurotoxicity is relatively rare, it can present with dramatic, fluctuating neurological deficits that mimic other serious conditions. Diagnosis may be complicated by the frequent presence of asymptomatic white matter abnormalities on MRI, commonly attributed to chronic MTX toxicity.

We report an 18-year-old ALL patient who developed severe, fluctuating neurological symptoms 11 days after the third intrathecal administration of MTX. MRI showed bilateral, symmetric diffusion-restrictive white matter lesions. Absent cortical motor evoked potentials (MEPs) with preserved responses to spinal stimulation indicated corticospinal tract involvement localized to the brain, supporting a diagnosis of MTX-induced neurotoxicity. Treatment with high-dose dextromethorphan led to rapid and complete recovery.

This case underscores the value of early neurophysiological testing – particularly MEPs – in identifying corticospinal tract involvement and differentiating symptomatic neurotoxicity from chronic, asymptomatic MRI findings. Prompt recognition can accelerate diagnosis, guide treatment, and prevent unnecessary interventions.

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甲氨蝶呤诱导的神经毒性：诊断挑战和神经生理测试的作用

甲氨蝶呤（MTX）广泛用于治疗急性淋巴细胞白血病（ALL）和其他肿瘤血液系统疾病。虽然亚急性mtx相关的神经毒性相对罕见，但它可以表现出戏剧性的，波动的神经功能障碍，类似于其他严重疾病。由于MRI上经常出现无症状的白质异常，诊断可能会变得复杂，通常归因于慢性MTX毒性。我们报告了一位18岁的ALL患者，他在第三次鞘内给药MTX 11天后出现了严重的、波动的神经系统症状。MRI显示双侧对称弥漫性白质病变。脊髓刺激反应保留的皮质运动诱发电位（MEPs）缺失表明皮质脊髓束受累局限于大脑，支持mtx诱导的神经毒性诊断。大剂量右美沙芬治疗可迅速完全恢复。本病例强调了早期神经生理检查（尤其是MEPs）在识别皮质脊髓束受累和区分症状性神经毒性与慢性无症状MRI表现方面的价值。及时识别可以加快诊断、指导治疗并防止不必要的干预。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Clinical Neurophysiology Practice NEUROSCIENCES-

CiteScore

3.90

自引率

0.00%

发文量

审稿时长

71 days

期刊介绍： Clinical Neurophysiology Practice (CNP) is a new Open Access journal that focuses on clinical practice issues in clinical neurophysiology including relevant new research, case reports or clinical series, normal values and didactic reviews. It is an official journal of the International Federation of Clinical Neurophysiology and complements Clinical Neurophysiology which focuses on innovative research in the specialty. It has a role in supporting established clinical practice, and an educational role for trainees, technicians and practitioners.