title: 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.
abstract: 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.
authors.affiliation: Department of Medicine, University of Massachusetts Medical Center, Worcester 01655, USA.
authors.forename: D M
authors.initials: DM
authors.lastname: Savarese
authors.forename: J
authors.initials: J
authors.lastname: Gordon
authors.forename: T W
authors.initials: TW
authors.lastname: Smith
authors.forename: N S
authors.initials: NS
authors.lastname: Litofsky
authors.forename: R
authors.initials: R
authors.lastname: Licho
authors.forename: R
authors.initials: R
authors.lastname: Ragland
authors.forename: L
authors.initials: L
authors.lastname: Recht
mesh_terms: 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
chemical_list: D000970:Antineoplastic Agents; D007978:Levamisole; D005472:Fluorouracil