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A Stroke Mimic: Methotrexate-induced Neurotoxicity in the Emergency Department

  • Patrick Rogers
    Correspondence
    Corresponding Address: Patrick Rogers, do, Department of Emergency Medicine, Rutgers–Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, New Brunswick, NJ 08901
    Affiliations
    Department of Emergency Medicine, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey
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  • Wilbur J. Pan
    Affiliations
    Department of Pediatric Hematology Oncology, Rutgers Cancer Institute of New Jersey, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey
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  • Richard A. Drachtman
    Affiliations
    Department of Pediatric Hematology Oncology, Rutgers Cancer Institute of New Jersey, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey
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  • Christopher Haines
    Affiliations
    Department of Pediatrics, Children's Specialized Hospital, Rutgers–Robert Wood Johnson Medical School, New Brunswick, New Jersey

    Department of Pediatric Emergency Medicine, Bristol-Myers Squibb Children's Hospital, New Brunswick, New Jersey
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      Abstract

      Background

      Acute lymphoblastic leukemia (ALL) is the most common form of childhood leukemia. The treatment of ALL involves multimodality therapy, and methotrexate (MTX) remains a mainstay of treatment. A complication of MTX therapy includes acute, subacute, and chronic neurotoxocity. Signs and symptoms may range from headaches, dizziness, and mood disorders to seizures and stroke-like symptoms.

      Case Report

      An 18-year-old woman with a history of ALL presented to the emergency department with acute onset of right-sided facial paralysis, right upper extremity flaccid paralysis, and right lower extremity weakness after receiving MTX therapy 3 days earlier. Diagnostic studies were unremarkable and the patient was treated with oral dextromethorphan for presumed MTX-induced neurotoxicity. The patient's symptoms began to improve within hours and she was discharged home within 48 hours with no neurologic deficits.

      Why Should an Emergency Physician Be Aware of This?

      Emergency physicians should be aware of this complication of MTX therapy given the sensitivity in regards to time with respect to cerebral vascular accidents. An awareness of this complication in the setting of the appropriate history and physical examination can lead to an accurate diagnosis and intervention and the avoidance of administering thrombolytics.

      Keywords

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