INTRATHECAL CHEMOTHERAPY-RELATED MYELOENCEPHALOPATHY IN A YOUNG-CHILDWITH ACUTE LYMPHOBLASTIC-LEUKEMIA

Since the mid-1960s intrathecal chemotherapy (methotrexate [MTX], cyta rabine [Ara-C], or both, plus hydrocortisone) has constituted the stan dard approach to prophylaxis and treatment of central nervous system ( CNS) leukemia and lymphoma. Intrathecal chemotherapy-related neurotoxi city has been described in a variable proportion of patients. At least 35 cases of subacute myeloencephalopathy with transient or permanent paraplegia/quadriplegia after intrathecal chemotherapy have been repor ted. Different factors have been cited: high cumulative MTX dose, meni ngeal leukemia, cranial irradiation, and preservatives in MTX and Ara- C. A direct toxic effect of the intrathecal chemotherapy seems the mos t likely mechanism. Early imaging studies are usually normal. We descr ibe a nonfatal case of permanent flaccid quadriplegia after the fourth triple intrathecal chemotherapy in a 6-year-old girl with acute lymph oblastic leukemia and no evidence of meningeal involvement. Six months after intrathecal chemotherapy, CNS magnetic resonance imaging showed severe atrophy of spine, cerebellum, and cerebral hemispheres. The ou tcome of reported cases is diverse. No treatment has been shown to rev erse neurotoxicity. Among the cases reported in the literature, comple te recovery of neurologic deficits was observed in 9 patients, partial recovery with variable sequelae in 6, no recovery in 8, and 13 patien ts died from the initial oncologic disease or neurotoxicity progressio n.