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Alternating hemiparesis and orolingual apraxia as manifestations of methotrexate neurotoxicity in a paediatric case of acute lymphoblastic leukaemia
  1. Siew Mei Yap1,
  2. Peter MacEneaney2,
  3. Clodagh Ryan3,
  4. Orna O'Toole1
  1. 1Department of Neurology, Mercy University Hospital, Cork, Ireland
  2. 2Department of Radiology, Mercy University Hospital, Cork, Ireland
  3. 3Department of Haematology, Mercy University Hospital, Cork, Ireland
  1. Correspondence to Dr Siew Mei Yap, siewmeiy{at}


A 15-year-old girl with a recent diagnosis of acute lymphoblastic leukaemia was admitted to hospital with pancytopaenia after having received high-dose intrathecal methotrexate 1 day prior. During the next week she had intermittent episodes of alternating hemiparesis associated with speech arrest lasting minutes to hours at a time. The episodes were not associated with altered level of consciousness or headache. MRI of the brain showed features consistent with methotrexate encephalopathy. This report discusses the typical clinical and radiological features of methotrexate neurotoxicity in addition to differential diagnoses and the proposed pathophysiological mechanisms.

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