Cerebral demyelination syndrome in a patient treated with 5-fluorouracil and levamisole. The use of thallium SPECT imaging to assist in noninvasive diagnosis--a case report.
BACKGROUND
The use of 5-fluorouracil (5-FU) and levamisole in patients with Stage III adenocarcinoma of the colon has now become standard. There have been several reports of a multifocal cerebral demyelination syndrome following 5-FU and levamisole administration.


METHODS
We describe a patient who developed focal neurologic symptoms while being treated with levamisole and 5-FU in whom the diagnosis of central nervous system (CNS) metastases was considered.


RESULTS
A magnetic resonance imaging (MRI) scan showed a diffuse, multifocal white matter process. Diagnostic evaluation did not support a diagnosis of CNS metastasis. 201Thallium chloride single photon emission computed tomography (SPECT) study was cold. A stereotactic brain biopsy disclosed demyelination but not tumor. The patient had complete functional resolution of symptoms with 1 month of dexamethasone therapy, although follow-up MRI scans have shown persistent abnormality on T2-weighted images.


CONCLUSIONS
In patients receiving 5-FU and levamisole who develop focal neurologic symptoms with an abnormal MRI scan, the diagnosis of CNS metastasis should not be made without a thorough diagnostic evaluation. We suggest the use of 201thallium chloride SPECT imaging to support the diagnosis of multifocal leukoencephalopathy related to 5-FU and levamisole. In atypical cases, a stereotactic brain biopsy may be required for confirmation.
Savarese
D M
DM
Department of Medicine, University of Massachusetts Medical Center, Worcester 01655, USA.
Gordon
J
J
Smith
T W
TW
Litofsky
N S
NS
Licho
R
R
Ragland
R
R
Recht
L
L
D000230:Adenocarcinoma / Q000188:drug therapy; D000368:Aged; D000818:Animals; D000970:Antineoplastic Agents / Q000009:adverse effects*; D001927:Brain Diseases / Q000139:chemically induced* / Q000175:diagnosis / Q000000981:diagnostic imaging; D003110:Colonic Neoplasms / Q000188:drug therapy; D003711:Demyelinating Diseases / Q000139:chemically induced* / Q000175:diagnosis / Q000000981:diagnostic imaging; D005260:Female; D005472:Fluorouracil / Q000009:adverse effects*; D006801:Humans; D007978:Levamisole / Q000009:adverse effects*; D008279:Magnetic Resonance Imaging; D014055:Tomography, Emission-Computed
D000970:Antineoplastic Agents; D007978:Levamisole; D005472:Fluorouracil