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January 26, 2021; 96 (4) NeuroImages

Nelarabine-Induced Myelotoxicity

Ajay A. Madhavan, View ORCID ProfileCarrie M. Carr, Hassan Alkhateeb, Nathan P. Staff, View ORCID ProfileElie Naddaf
First published December 11, 2020, DOI: https://doi.org/10.1212/WNL.0000000000011343
Ajay A. Madhavan
From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN.
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Carrie M. Carr
From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN.
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  • ORCID record for Carrie M. Carr
Hassan Alkhateeb
From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN.
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Nathan P. Staff
From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN.
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Elie Naddaf
From the Departments of Radiology (A.A.M., C.M.C.), Hematology and Oncology (H.A.), and Neurology (N.P.S., E.N.), Mayo Clinic, Rochester, MN.
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Nelarabine-Induced Myelotoxicity
Ajay A. Madhavan, Carrie M. Carr, Hassan Alkhateeb, Nathan P. Staff, Elie Naddaf
Neurology Jan 2021, 96 (4) 175-176; DOI: 10.1212/WNL.0000000000011343

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A 29-year-old woman with relapsed T-cell acute lymphoblastic leukemia presented with 4 months of progressive ataxia, weakness, and bowel/bladder incontinence. Symptoms started after completing 2 cycles of nelarabine. Examination revealed paraplegia and complete sensory loss from mid-chest down, loss of vibration and joint position in upper limbs, areflexia, and bilateral Babinski signs. EMG showed fibrillation potentials with no activated motor units in lower limbs. Laboratory workup, including paraneoplastic autoantibody panel, CSF analysis, vitamin B12, methylmalonic acid, and copper levels, was unremarkable. Spine MRI findings were consistent with nelarabine-induced subacute combined degeneration, including previously unreported lateral column involvement and cord enhancement (figure).1,2 The unremarkable CSF, MRI findings (tractopathy), and subacute course made alternative etiologies such as infection, infiltrative leukemia, ischemia, or cord hemorrhage less likely. The patient was treated conservatively and started to spontaneously improve. She then underwent allogenic stem cell transplantation. Three months later, she regained movement against gravity in all lower extremity muscles. However, she remained severely ataxic, requiring the use of a wheelchair. Repeat EMG showed reinnervation in most lower-limb muscles and less frequent fibrillation potentials.

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Figure Nelarabine-Induced Myelotoxicity

MRI of the cervical (A, C, and E) and thoracic (B and D) spine. Sagittal T2-weighted (A), sagittal short tau inversion recovery (B), axial T2-weighted (C–D), and axial T1-weighted postcontrast (E) images demonstrate extensive T2 hyperintensity of the dorsal (A–D, arrows) and lateral columns (D, dashed arrows), with dorsal column enhancement at the cervicomedullary junction (E, arrowhead).

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No targeted funding reported.

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The authors report no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.

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Footnotes

  • Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • © 2020 American Academy of Neurology

References

  1. 1.↵
    1. Lalayanni C,
    2. Baldoumi E,
    3. Papayiannopoulos S,
    4. Tziola K,
    5. Saloum R,
    6. Anagnostopoulos A
    . Nelarabine-associated reversible Guillain-Barre-like syndrome or myelopathy in an adult patient with primary refractory T-lymphoblastic lymphoma. Curr Probl Cancer 2017;41:138–143.
    OpenUrl
  2. 2.↵
    1. Kawakami M,
    2. Taniguchi K,
    3. Yoshihara S, et al
    . Irreversible neurological defects in the lower extremities after haploidentical stem cell transplantation: possible association with nelarabine. Am J Hematol 2013;88:853–857.
    OpenUrlCrossRefPubMed

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