Disseminated necrotizing leukoencephalopathy following low-dose oral methotrexate

Eur J Neurol. 2007 Mar;14(3):309-14. doi: 10.1111/j.1468-1331.2006.01659.x.

Abstract

Leukoencephalopathy is a recognized complication with intrathecal or intravenous methotrexate (MTX). We report a 59-year-old lady who developed MTX leukoencephalopathy with long-term low-dose oral MTX. She developed posterior leukoencephalopathy (PLE) that initially was reversible on discontinuation of oral MTX. Four months later, she developed disseminated necrotizing leukoencephalopathy (DNL), and was left with devastating neurological deficits. The sequential conventional magnetic resonance imaging (MRI), diffusion weighted imaging (DWI), MR perfusion (MRP) and MR spectroscopic (MRS) changes are highlighted in this report. MRP and MRS showed more wide spread abnormalities than DWI. Stereotactic biopsy from the lesion revealed demyelination with macrophagic infiltration, pericapillary lymphomononuclear aggregation, fibrinoid changes in the capillaries and neovascularization. Of the two cases of PLE with oral MTX reported in literature, one reversed clinically and radiologically with the discontinuation of MTX. To the best of our knowledge, this is the first reported case of DNL following oral MTX in the world literature.

Publication types

  • Case Reports

MeSH terms

  • Antirheumatic Agents / administration & dosage
  • Antirheumatic Agents / adverse effects
  • Arthritis, Rheumatoid / drug therapy
  • Brain Damage, Chronic / chemically induced*
  • Brain Damage, Chronic / pathology
  • Brain Damage, Chronic / physiopathology
  • Brain Edema / chemically induced
  • Brain Edema / pathology
  • Brain Edema / physiopathology
  • Cerebral Arteries / drug effects
  • Cerebral Arteries / pathology
  • Cerebral Arteries / physiopathology
  • Cognition Disorders / chemically induced
  • Cognition Disorders / pathology
  • Cognition Disorders / physiopathology
  • Dexamethasone / therapeutic use
  • Diffusion Magnetic Resonance Imaging
  • Dose-Response Relationship, Drug
  • Female
  • Gliosis / chemically induced
  • Gliosis / pathology
  • Gliosis / physiopathology
  • Glucocorticoids / therapeutic use
  • Humans
  • Methotrexate / administration & dosage
  • Methotrexate / adverse effects*
  • Middle Aged
  • Nerve Fibers, Myelinated / drug effects*
  • Nerve Fibers, Myelinated / pathology
  • Neurodegenerative Diseases / chemically induced*
  • Neurodegenerative Diseases / pathology
  • Neurodegenerative Diseases / physiopathology
  • Telencephalon / diagnostic imaging
  • Telencephalon / drug effects*
  • Telencephalon / pathology
  • Tomography, X-Ray Computed
  • Treatment Outcome

Substances

  • Antirheumatic Agents
  • Glucocorticoids
  • Dexamethasone
  • Methotrexate