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Abstract Details

An Adult Case of Methotrexate-related Stroke-like Encephalopathy Responsive to Dextrometorphan
Neuro-oncology
P4 - Poster Session 4 (8:00 AM-9:00 AM)
6-001
  • To report that MTX-induced stroke-like encephalopathy can respond to the N-methyl-D-aspartate receptor agonist dextromethorphan at a dose range of 1.4-2.3 mg/kg/day for 4-14 doses in adults.  

 

Methotrexate (MTX)-induced stroke-like encephalopathy is a rare neurological complication after administration of the chemotherapeutic agent MTX via intravenous or intrathecal route and can be responsive to high-dose leucovorin or off-label dextromethorphan. Limited data are available on the dosage and efficacy of dextromethorphan administration in MTX-induced stroke-like encephalopathy in adults compared to children. 
N/A
We present a case of a 39-year-old Hispanic woman with B-cell acute lymphoblastic leukemia who presented with one day of sudden-onset left leg and arm weakness and generalized fatigue occurring 18 and 10 days after receiving 15 mg of intratechal MTX. Neurological exam on presentation was significant for 4+/5 in the left upper and 4/5 in the left lower extremities. MRI of the brain revealed focal restricted diffusion of the right centrum semiovale extending to the vertex without corresponding T2/fluid-attenuated inversion recovery (FLAIR) sequence signal abnormality. She was diagnosed with MTX-induced stroke-like encephalopathy. Leucovorin 8 mg administered every twelve hours was started without symptom improvement. On hospital day two, her symptoms worsened, and she was started on dextromethorphan 1.9 mg/kg/day divided into three doses per day for five days. After five days, she was able to ambulate again and the neurological exam revealed 5/5 strength in all muscle groups of the left upper and lower extremity, except for 4/5 in the left digit flexors. She was full strength at her two-month post-discharge outpatient neurology visit.

MTX-induced stroke-like encephalopathy can respond to dextromethorphan treatment in adults with complete resolution of symptoms. While a dose range of 1.4-2.3 mg/kg/day for 4-14 doses has been reported in one case series, further reports and larger studies are needed to refine the dextromethorphan administration parameters. 
Authors/Disclosures
Michele Persico, MD
PRESENTER 		Dr. Persico has nothing to disclose.
Christy Soares, MD (Emory University Hospital) Dr. Soares has nothing to disclose.
Tyler Kristoff, MD The institution of Dr. Kristoff has received research support from Winship Cancer Institute . Dr. Kristoff has received intellectual property interests from a discovery or technology relating to health care.
Nikolaos papadantonakis, MD, PhD The institution of Dr. papadantonakis has received research support from Agios . The institution of Dr. papadantonakis has received research support from Novartis . The institution of Dr. papadantonakis has received research support from Curis . The institution of Dr. papadantonakis has received research support from Gilead . Dr. papadantonakis has received personal compensation in the range of $500-$4,999 for serving as a panelist with Adept Field Solutions.
Sara Radmard, MD Dr. Radmard has nothing to disclose.