Successful therapeutic rechallenge after a severe episode of high dose methotrexate‑induced choreoathetosis: A case report

Chong,Lip  Leong; Wong,Evelyn  Yi Ting; Santos‑Banta,Sheryl  Lyn Lucero; Cheng,Chee  Leong; Tan,Leonard; Poon,Eileen  Yi Ling; Somasundaram,Nagavalli; Farid,Mohamad; Tang,Tiffany; Tao,Miriam; Khoo,James  Boon Kheng; Shih,Vivianne; Cheah,Daryl  Ming Zhe; Ong,Choon  Kiat; Lim,Soon  Thye; Chan,Jason  Yongsheng

doi:10.3892/mco.2019.1898

Successful therapeutic rechallenge after a severe episode of high dose methotrexate‑induced choreoathetosis: A case report

Authors:
- Lip Leong Chong
- Evelyn Yi Ting Wong
- Sheryl Lyn Lucero Santos‑Banta
- Chee Leong Cheng
- Leonard Tan
- Eileen Yi Ling Poon
- Nagavalli Somasundaram
- Mohamad Farid
- Tiffany Tang
- Miriam Tao
- James Boon Kheng Khoo
- Vivianne Shih
- Daryl Ming Zhe Cheah
- Choon Kiat Ong
- Soon Thye Lim
- Jason Yongsheng Chan
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Affiliations: Division of Medical Oncology, National Cancer Centre Singapore, Singapore 169610, Republic of Singapore, Department of Anatomical Pathology, Singapore General Hospital, Singapore 169608, Republic of Singapore, Department of Oncologic Imaging, National Cancer Centre, Singapore 169610, Republic of Singapore, Department of Pharmacy, National Cancer Centre Singapore, Singapore 169610, Republic of Singapore, Lymphoma Genomic Translational Research Laboratory, Division of Cellular and Molecular Research, National Cancer Centre Singapore, Singapore 169610, Republic of Singapore, Duke‑NUS Medical School, Singapore 169857, Republic of Singapore
Published online on: July 16, 2019 https://doi.org/10.3892/mco.2019.1898
Pages: 354-358
Copyright : © Chong et al. This is an open access article distributed under the terms of Creative Commons Attribution License [CC BY 4.0].

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Abstract

Methotrexate (MTX) is an essential chemotherapy drug used in the treatment of malignancies, but it is known to cause complications to the central nervous system. We report a case of severe MTX neurotoxicity in an adult presenting with choreoathetosis despite a normal clearance of MTX. High dose‑MTX has been successfully rechallenged without any neurological sequelae. We reviewed the relevant literature of similar manifestations and summarized their clinical data, magnetic resonance imaging features and treatment given. None of them has recurrence of neurotoxicity. We concluded that it is safe to persist with MTX even after a previous episode of toxic leukoencephalopathy.

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1	Howard SC, McCormick J, Pui CH, Buddington RK and Harvey RD: Preventing and managing toxicities of high-dose methotrexate. Oncologist. 21:1471–1482. 2016. View Article : Google Scholar : PubMed/NCBI
2	Rollins N, Winick N, Bash R and Booth T: Acute methotrexate neurotoxicity: Findings on diffusion-weighted imaging and correlation with clinical outcome. AJNR AM J Neuroradiol. 25:1688–1695. 2004.PubMed/NCBI
3	Vagace JM, de la Maya MD, Caceres-Marzal C, Gonzalez de Murillo S and Gervasini G: Central nervous system chemotoxicity during treatment of pediatric acute lymphoblastic leukemia/lymphoma. Crit Rev Oncol Hematol. 84:274–286. 2012. View Article : Google Scholar : PubMed/NCBI
4	Bhojwani D, Sabin ND, Pei D, Yang JJ, Khan RB, Panetta JC, Krull KR, Inaba H, Rubnitz JE, Metzger ML, et al: Methotrexate-induced neurotoxicity and leukoencephalopathy in childhood acute lymphoblastic leukemia. J Clin Oncol. 32:949–959. 2014. View Article : Google Scholar : PubMed/NCBI
5	Shah GD, Yahalom J, Correa DD, Lai RK, Raizer JJ, Schiff D, LaRocca R, Grant B, DeAngelis LM and Abrey LE: Combined immunochemotherapy with reduced whole-brain radiotherapy for newly diagnosed primary CNS lymphoma. J Clin Oncology. 25:4730–4735. 2007. View Article : Google Scholar
6	Walker RH: Differential diagnosis of chorea. Curr Neurol Neurosci Rep. 11:385–395. 2011. View Article : Google Scholar : PubMed/NCBI
7	McKinney AM, Kieffer SA, Paylor RT, SantaCruz KS, Kendi A and Lucato L: Acute toxic leukoencephalopathy: Potential for reversibility clinically and on MRI with diffusion-weighted and FLAIR imaging. AJR AM J Roentgenol. 193:192–206. 2009. View Article : Google Scholar : PubMed/NCBI
8	Hegde AN, Mohan S, Lath N and Lim CC: Differential diagnosis for bilateral abnormalities of the basal ganglia and thalamus. Radiographics. 31:5–30. 2011. View Article : Google Scholar : PubMed/NCBI
9	Inaba H, Khan RB, Laningham FH, Crews KR, Pui CH and Daw NC: Clinical and radiological characteristics of methotrexate-induced acute encephalopathy in pediatric patients with cancer. Ann Oncol. 19:178–184. 2008. View Article : Google Scholar : PubMed/NCBI
10	Necioğlu Orken D, Yldrmak Y, Kenangil G, Kandraloğlu N, Forta H and Celik M: Intrathecal methotrexate-induced acute chorea. J Pediatr Hematol Oncol. 31:57–58. 2009. View Article : Google Scholar : PubMed/NCBI
11	Bota DA and Dafer RM: Acute methotrexate neurotoxicity with choreiform movements and focal neurological deficits: A case report. South Med J. 102:1071–1074. 2009. View Article : Google Scholar : PubMed/NCBI
12	Valle DA, Kakehasi FM, Melo RM, Siqueira CM, Soares TF and Rodrigues KE: Stroke-like encephalopathy following high-dose intravenous methotrexate in an adolescent with osteosarcoma: A case report. Rev Bras Hematol Hemoter. 38:364–367. 2016. View Article : Google Scholar : PubMed/NCBI
13	Tsurusawa M, Gosho M, Mori T, Mitsui T, Sunami S, Kobayashi R, Fukano R, Tanaka F, Fujita N, Inada H, et al: Statistical analysis of relation between plasma methotrexate concentration and toxicity in high-dose methotrexate therapy of childhood nonHodgkin lymphoma. Pediatr Blood Cancer. 62:279–284. 2015. View Article : Google Scholar : PubMed/NCBI
14	Lam DST, Khong PL, Chiang AKS, Ha SY, Lau YL and Chan GCF: Reversible encephalopathy induced by systemic high dose methotrexate. HK J Paediatr. 12:287–292. 2007.
15	Bernini JC, Fort DW, Griener JC, Kane BJ, Chappell WB and Kamen BA: Aminophylline for methotrexate-induced neurotoxicity. Lancet. 345:544–547. 1995. View Article : Google Scholar : PubMed/NCBI
16	Fernández-Fernández FJ, Ameneiros-Lago E, Lijó-Carballeda C and Sesma P: Dextromethorphan and methylxanthines might be useful in the treatment of methotrexate-induced neurotoxicity. Pediatr Emerg Care. 33:3802017. View Article : Google Scholar : PubMed/NCBI
17	Salkade PR and Lim TA: Methotrexate-induced acute toxic leukoencephalopathy. J Cancer Res Ther. 8:292–296. 2012. View Article : Google Scholar : PubMed/NCBI