(Kiosk 4) Rare Case of Progressive Irreversible Myelopathy After Intrathecal Treatment for Diffuse Large B Cell Lymphoma

Case Diagnosis: 73 year-old female admitted to inpatient rehabilitation with progression of neurological symptoms that resembled a Non-traumatic Spinal Cord Injury(NTSCI) with intrathecal chemotoxicity as most likely etiology.

Case Description: Patient with history of Central nervous system(CNS) involved Diffuse Large B-cell Lymphoma with recent relapse admitted for recurrent falls and new bowel/bladder incontinence. Cerebrospinal fluid cytometry was negative. Imaging demonstrated multilevel neuroforaminal stenosis--deemed unlikely to be the cause of her symptoms. Electromyography/Nerve Conduction Study demonstrated distal motor polyneuropathy. Patient eventually admitted to acute inpatient rehabilitation for strengthening before resuming chemotherapy. She demonstrated progression of symptoms while in rehab. Found to have ascending sensory loss (knee level on admission progressing to groin level) and ascending motor weakness (Hip-flexion 4/5 initially to less than antigravity strength). Patient transferred back to acute service for work up. Repeat imaging, infectious and autoimmune work up negative. Repeat flow cytometry and pathology negative for CNS lymphoma. Patient completed steroid, Intravenous Immunoglobulin(IVIG), and plasmapheresis courses with no improvement. Final diagnosis was toxic-myelopathy from intrathecal Cytarabine and Methotrexate with flaccid paralysis and neurogenic bowel/bladder. Patient transitioned back to inpatient rehabilitation with goals at primarily wheelchair level.

Discussion: Transient/permanent neurotoxic side effects of intrathecal Cytarabine and Methotrexate have a reported incidence of less than 3%. Her progressive symptoms during inpatient rehabilitation illustrate the prompt action taken by the physiatrist to diagnose potential causes of progressive NTSCI symptoms.

Setting: Inpatient Rehab

Assessment/Results: After extensive work-up and given the timing of intrathecal Methotrexate and Cytarabine just prior to symptoms, it was believed the cause of her presentation was likely intrathecal chemotherapy toxicity.

Conclusion: Such severe and irreversible myelopathies as described in this report are rare with intrathecal chemotherapy. The goal of this report was to highlight the symptoms of this patient as a NTSCI injury. Attention should be paid to ensure proper work up and management of such future cases.