title: Levamisole-induced multifocal inflammatory leukoencephalopathy: clinical characteristics, outcome, and impact of treatment in 31 patients.
abstract: Levamisole (LEV) has been used as an immunomodulating medication in patients with recurrent aphthous ulcers and as an adjuvant for chemotherapy. LEV, with or without 5-fluorouracil (5-FU), induces multifocal inflammatory leukoencephalopathy (MIL). We identified 31 patients with LEV-induced MIL: 7 from our institution and 24 from a MEDLINE search. Twenty-one patients (67.7%) had been treated with a combination of LEV and 5-FU, while 10 patients had been treated with LEV alone. The onset of MIL was delayed in patients who took LEV and 5-FU in combination compared with the patients treated with LEV alone (11.7 +/- 3.7 vs. 4 +/- 2.5 wk, p < 0.001). Colon cancer (67.7%) was the most common indication for LEV administration. Gait ataxia occurred in 20 (64.5%) patients, and dysphagia was noted in 16 (51.6%) patients. Imaging studies revealed periventricular enhancement in 17 (54.8%) patients and supratentorial lesions in 16 (51.6%) patients. Cerebrospinal fluid studies showed lymphocytic pleocytosis in 10 of 21 (47.6%) patients. Early diagnosis of MIL and discontinuation of LEV is essential, yielding good recovery in most cases. Treatment with corticosteroids and/or intravenous immunoglobulin may be needed for this serious inflammatory encephalopathy. Twenty-nine patients exhibited improved clinical status and imaging findings after initial steroid or immunoglobulin treatment. Plasmapheresis may be an alternative regimen for patients with steroid resistance.
authors.affiliation: From Department of Internal Medicine (VCW, YHL, JJH), Yun-Lin Branch of National Taiwan University Hospital; Departments of Internal Medicine (VCW, JWH, YHL, JJH, KDW), Pathology (HCL), Neurology (STH, CCY), and Imaging (HML), National Taiwan University Hospital, Taipei, Taiwan.
authors.forename: Vin-Cent
authors.initials: VC
authors.lastname: Wu
authors.forename: Jenq-Wen
authors.initials: JW
authors.lastname: Huang
authors.forename: Huang-Chun
authors.initials: HC
authors.lastname: Lien
authors.forename: Sung-Tsang
authors.initials: ST
authors.lastname: Hsieh
authors.forename: Hon-Man
authors.initials: HM
authors.lastname: Liu
authors.forename: Chih-Chao
authors.initials: CC
authors.lastname: Yang
authors.forename: Yen-Hung
authors.initials: YH
authors.lastname: Lin
authors.forename: Juey-Jen
authors.initials: JJ
authors.lastname: Hwang
authors.forename: Kwan-Dun
authors.initials: KD
authors.lastname: Wu
mesh_terms: D000328:Adult; D000368:Aged; D003110:Colonic Neoplasms / Q000188:drug therapy; D005260:Female; D006801:Humans; D007968:Leukoencephalopathy, Progressive Multifocal / Q000139:chemically induced* / Q000628:therapy; D007978:Levamisole / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D010956:Plasmapheresis; D013256:Steroids / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D013256:Steroids; D007978:Levamisole