Tariq Hamza, Gilbert Andrea, Sharkey Francis E
Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, TX, USA.
Clin Med Insights Pathol. 2018 Nov 4;11:1179555718809071. doi: 10.1177/1179555718809071. eCollection 2018.
Central nervous system (CNS) relapse of acute lymphoblastic leukemia (ALL) is associated with a poor prognosis. However, prophylactic measures, including intrathecal (IT) methotrexate, reduce the incidence of CNS relapse in these patients considerably. Unfortunately, IT methotrexate can cause several neurologic complications, including transverse myelopathy; ie, the development of isolated spinal cord dysfunction over hours or days following the IT infusion of methotrexate, but in the absence of a compressive lesion. Transverse myelopathy following IT methotrexate is a well-established clinical phenomenon, but the histologic features have been described only very rarely. We report the autopsy findings from a 31-year-old man with a history of T-cell ALL who received prophylactic IT methotrexate in anticipation of a bone marrow transplant. Microscopic examination showed transverse necrosis of the thoracic cord, with massive infiltration by macrophages and lymphocytes, and perivascular lymphocytic infiltrates. There was cavitary necrosis of cervical and lumbar spinal cord involving the entire gray matter and focal white matter, as well as extensive subpial vacuolar degeneration of the dorsal and lateral columns.
急性淋巴细胞白血病（ALL）的中枢神经系统（CNS）复发与预后不良相关。然而，包括鞘内注射（IT）甲氨蝶呤在内的预防措施可显著降低这些患者CNS复发的发生率。不幸的是，IT甲氨蝶呤可导致多种神经并发症，包括横贯性脊髓病；即在IT注射甲氨蝶呤数小时或数天内出现孤立的脊髓功能障碍，但不存在压迫性病变。IT甲氨蝶呤后的横贯性脊髓病是一种公认的临床现象，但组织学特征很少被描述。我们报告了一名31岁男性的尸检结果，该男性有T细胞ALL病史，在预期进行骨髓移植时接受了预防性IT甲氨蝶呤治疗。显微镜检查显示胸段脊髓横贯性坏死，有大量巨噬细胞和淋巴细胞浸润以及血管周围淋巴细胞浸润。颈段和腰段脊髓有空洞性坏死，累及整个灰质和局灶性白质，以及背侧和外侧柱广泛的软膜下空泡变性。
