Mesial temporal sclerosis as a complication of hematologic cancer

Abstract

Seizures may occur in patients with hematological malignancies usually associated with central nervous system (CNS) metastasis or treatment toxicity [1]. However, development of temporal epilepsy due to mesial temporal sclerosis (MTS) in patients with leukemia or lymphoma is extremely rare. Here we report two patients who developed MTS after treatment for hematologic cancer. Patient 1 A previously healthy 59-year-old man was admitted for treatment of newly diagnosed acute promyelocytic leukemia. Induction chemotherapy included transretinoic acid and idarubicin. Two weeks after admission he developed pneumonia, sepsis and acute renal failure. After stabilization, and under treatment for severe hypertension, he had a 5-min generalized tonic–clonic seizure. Magnetic resonance image (MRI) showed bilateral occipital abnormalities consistent with posterior reversible encephalopathy syndrome (PRES). Mild hyperintensity of the left hypocampus in T2-weighted FLAIR images was observed, with normal volume of both hippocampi (Fig. 1a, b). The patient was started on levetiracetam that was discontinued after two seizure-free weeks. After discharge, he received trans-retinoic acid, idarubicin and mitoxantrone. Two months later, the patient developed seizures consisting of a rising epigastric sensation followed by right hemicorporal tingling. Control MRI showed left hipocampal sclerosis (Fig. 1c, d). Levetiracetam was reintroduced and at 1–year follow–up seizure control was good. Patient 2 A 21-year-old woman was referred for evaluation of intractable partial epilepsy. She had been well until 13 years of age when she was diagnosed of nonHodgkin lymphoblastic lymphoma. Chemotherapy included vincristine, daunorubicin, prednisone, L-asparaginase, cyclophosfamide and intrathecal methotrexate, cytarabine and hydrocortisone. No immediate complications were recorded. One year later, shortly after finishing chemotherapy, she started with paroxysmal episodes consisting of epigastric rising sensation followed by a short period of disconnection. A brain MRI performed in other center was reported as normal. Treatment with carbamacepine was started, with acceptable seizure control until the age of 20, when she developed very frequent seizures unresponsive to several antiepileptic drugs, and was referred to our epilepsy unit. Comprehensive re-evaluation was performed, including a MRI that showed right MTS (Fig. 2). We reviewed the previous MRI that showed mild right hippocampus atrophy. Prolonged video-EEG monitoring showed a right temporal theta activity at seizure onset. Serum onconeural antibody analysis was negative. Surgical excision of the right anterior temporal pole, hippocampus and amygdala was performed. The pathological findings were consistent with MTS. Two years later the patient remains seizure free.