Chorea associated with a subdural hematoma in a child with leukemia

Abstract

Patient M. H., a 12-year-old Caucasian boy, developed acute lymphocytic leukemia in February, 1968, and was given systemic induction and maintenance chemotherapy, without central nervous system prophylaxis. A lumbar puncture performed in May, 1968, because of recurrent headache, lethargy, and vomiting, revealed 30 lymphoblasts/mm ~ CSF. A single dose of intrathecal methotrexate resulted in clearing of spinal fluid and resolution of the symptoms. A lumbar puncture two months later was normal. The child remained free of central nervous system symptoms until 1974. Bone marrow relapses in January and August, 1969, and February, 1970, were effectively treated. In December, 1974, massive weight gain, headache, nausea, and vomiting led to a diagnosis of meningeal leukemia with hypothalamic syndrome. The CSF contained 490 lymphoblasts/ mm -~, Results of a brain scan and EEG were normal. I ntrathecally administered cytosine arabinoside and methotrexate resulted in clearing of the spinal fluid and regression of symptoms. Only mild headache and nausea persisted. Intrathecal methotrexate was given weekly until February, 1975, and then administered monthly. In March, 24 hours after receiving intrathecal methotrexate, he developed a severe headache, nausea, and vomiting. In the following two weeks the parents noted increasing nervousness, incoordination, and unusual movements involving the patient's face, trunk, and extremities. His speech was difficult to understand. In retrospect, the parents felt that the abnormal movements may have preceded the lumbar puncture. No seizure activity was observed, but he periodically appeared to be dazed.