Presentation
History of B cell ALL. Currently receiving consolidation therapy, including intrathecal methotrexate. Now presenting with right-sided weakness.
Patient Data
There are patchy areas of reduced diffusivity (left greater than right) in the cerebral white matter of the frontal and parietal lobes including the centrum semiovale and corona radiata. There is a barely perceptible FLAIR signal. There is no abnormal enhancement associated with the diffusion abnormality.
Case Discussion
This is a case highly suggestive of methotrexate toxicity.
The patient initially presented with neurologic symptoms following several treatments of intrathecal methotrexate. An MRI of the brain demonstrated restricted diffusion within the cerebral white matter without associated significant T2/FLAIR signal or enhancement. Methotrexate levels were elevated. The patient was started on leucovorin, dexamethasone, and twice daily dextromethorphan, in which the patient began to improve. A follow up brain MRI (not shown) revealed persistent but mildly improved restricted diffusion.
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