Transient tetraparesis after intrathecal and high-dose systemic methotrexate

Aggressive polychemotherapy, intrathecal cytostatic prophylaxis and cranial irradiation have contributed to the remarkable improvement in the prognosi s of acute lymphoblastic leukemia (ALL) and subtypes of high-grade non-Hodg kin's lymphoma (NHL) and the reduction of central nervous system (CNS) rela pses. Early and late neurologic changes have been observed after different CNS-directed therapies. We re port on the rare event of an acute tetrapares is after methotrexate (MTX) without other CNS-directed therapy. A young fem ale with a diffuse large B-cell lymphoma developed signs of meningeal irrit ation a few hours after intrathecal prophylaxis with MTX, cytosine-arabinos ide and dexamethasone. She recovered quickly. Ten days after her last cours e of systemic chemotherapy including high dose MTX she was admitted with a tetraparesis and motoric aphasia. A computer assisted tomography (CT) scan was normal. On magnetic resonance imaging (MRI) hyperintense white matter l esions were visible in the periventricular white matter. Initially, the rad iologic signs were progressive while the patient's clinical condition impro ved. MRI controls after complete neurologic normalization revealed delayed partial regression of the white matter abnormalities. The patient has now b een free of neurologic symptoms for 16 months. This case report demonstrate s acute and subacute neurotoxic effects of MTX in the same patient and illu strates that radiologic CNS changes can persist irrespective of the disappe arance of clinical symptoms.