Neurotoxicity is a well-documented adverse effect of methotrexate in the treatment of pediatric cancers. The spectrum of symptoms is broad, can include stroke-like episodes and seizures, and classically resolves within days. The majority of patients tolerate subsequent doses without recurrence of symptoms. The population of patients who experience persistent and irreversible neurological symptoms is poorly described, with the existing literature suggestive of a relationship with radiation therapy. The authors present a case series of 2 patients with pre-B-cell acute lymphoblastic leukemia who developed severe and ultimately fatal methotrexate-related neurotoxicity in the absence of radiation. Keywords methotrexate; neurotoxicity syndromes; pediatric; pre-cursor cell lymphoblastic leukemialymphoma Oral, intravenous (IV) and intrathecal (IT) methotrexate (MTX) are essential medications in the treatment of many childhood malignancies, including acute lymphoblastic leukemia (ALL). MTX-related neurotoxicity is a well-documented adverse effect, despite leucovorin rescue. Between 3% and 15% of patients receiving MTX will develop neurotoxicity symptoms, with a highly variable presentation that can include altered mental status (AMS), seizures, and stroke-like episodes. 1 Episodes of neurotoxicity typically occur 3 to 11 days from the last dose of MTX and last minutes to days and typically resolve within 2 weeks. 2,3 Patients who have neurotoxicity rarely have a recurrence of symptoms when rechallenged with MTX but rarely patients can develop recurrences and severe neurological deficits. 4,5
COM/ABC/EFV or TZV/EFV produced potent, durable virologic suppression and immunologic benefits, was associated with high adherence rates, and was generally well tolerated.
Acute pediatric stroke is growing in incidence with the longer survivorship of children with medical complexities, yet detection and treatment of this disease continues to be met with limitations. It is essential for the frontline provider to appropriately identify various presentations of acute pediatric stroke for timely management to occur. Although studies in thrombolytic and endovascular recanalization therapies are limited, the safety and efficacy of these treatments continues to be explored. As pediatric tertiary care centers improve their stroke management, it is increasingly important to implement hospital protocols with a multifaceted approach. This article summarizes the issues and presentations behind identifying acute pediatric stroke, the research behind these emerging therapies in children, and the process of successfully applying pediatric stroke protocols.
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Pediatr Ann
. 2021;50(6):e242–e244.]
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