Central nervous system graft-versus-host disease in a 68-year-old man presenting with myoclonus

A 68-year-old man presented to the emergency department with a 1-week history of sudden-onset myoclonus of his right leg. His medical history included allogeneic hematopoietic stem cell transplantation for myelodysplastic syndrome performed 742 days earlier, type 2 diabetes mellitus, hypertension an...

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Bibliographic Details
Published in:Canadian Medical Association journal (CMAJ) 2019-09, Vol.191 (39), p.E1078-E1081
Main Authors: Wang, Xin, Billick, Maxime, Monsour, Danny, Liu, Jessica
Format: Article
Language:English
Subjects:
Acyclovir
Antigens
Antiviral drugs
B cells
Blood diseases
Bone marrow
Case studies
Central nervous system
Central nervous system diseases
Clinical medicine
Complications and side effects
Diabetes mellitus
Drug dosages
Encephalitis
Family medical history
Graft versus host disease
Hematopoietic stem cell transplantation
Herpes simplex
Herpes simplex virus
Herpes viruses
Herpesvirus infections
HLA antigens
Hypertension
Immunoglobulins
Infections
Internal medicine
Magnetic resonance imaging
Medicine
Mens health
Methotrexate
Mortality
Myoclonus
Nervous system
NMR
Nuclear magnetic resonance
Patients
Practice
Prophylaxis
Risk factors
Stem cell transplantation
Stem cells
Surgery
Transplants & implants
Type 2 diabetes
West Nile virus
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Summary:A 68-year-old man presented to the emergency department with a 1-week history of sudden-onset myoclonus of his right leg. His medical history included allogeneic hematopoietic stem cell transplantation for myelodysplastic syndrome performed 742 days earlier, type 2 diabetes mellitus, hypertension and dyslipidemia. The patient had undergone a 9/10 unrelated human leukocyte antigen donor transplantation, and after transplantation, his myelodysplastic syndrome was in complete remission and he had complete donor engraftment. On presentation, he was receiving methotrexate (10 mg by mouth weekly) for large granular lymphocytosis and acyclovir (400 mg by mouth twice daily) for herpes simplex virus prophylaxis. A detailed neurologic examination on presentation showed a right-sided pyramidal distribution of weakness and a stimulus-sensitive, spontaneous positive myoclonus, present in the right leg more than the arm, and absent in the face. This case highlights the importance of the late central nervous system complications of hematopoietic stem cell transplantation, the challenges with diagnosis and the role of timely immunosuppressive therapy.
ISSN:0820-3946
1488-2329
DOI:10.1503/cmaj.190216