Multifocal inflammatory levamisole-induced leukoencephalopathy in pediatric patient

Abstract

Levamizole is an imidazole derivative used in the treatment of various types of cancer, dermatological diseases and parasitoses. The drug has immunomodulatory properties due to stimulating the activity of macrophages, neutrophils, monocytes and T-lymphocytes. Common side effects are gastrointestinal disorders, skin manifestations and hematological disorders. There is also a wide range of neurological side effects, such as headache, dizziness, vomiting, aphasia, blurred vision, diplopia, weakness, which can be observed in 1.3-5.0% of patients. Multifocal levamizole-induced leukoencephalopathy is one of the most striking neurological side effects of levamizole. MRI of the brain in this pathology reveals numerous foci of demyelination, located mainly periventrically, in the white matter of the cerebral hemispheres, cerebellum, brain stem, corpus callosum, basal ganglia. The treatment with corticosteroids showed the significant improvement in the condition, with almost complete regression of neurological symptoms [8]. Although the symptoms are most often manifested as subacute, over 2-8 weeks of drug use, there were reported cases with clinical manifestations developed both 1 day and months after levamizole administration. It should be noted that the neurotoxic effects of levamizole can manifest independently on the dose, even after a single application of 50 mg, which indicates that its toxic effect is a manifestation of idiosyncrasy. The literature provides a sufficient number of descriptions of clinical manifestations, MRI features and therapy of drug complications of levamizole use in adults. However, observations in pediatric practice are few. We would like to present clinical, laboratory data, imaging results, information on the treatment and follow-up of a 17-year girl who developed levamizole-induced inflammatory leukoencephalopathy and autoimmune hepatitis after self-administration of levamizole for the prevention of helminthic invasion. Leukoencephalopathy caused by levamizole should be taken into account in the differential diagnosis of demyelinating diseases, including acute multiple encephalomyelitis and multiple sclerosis, and the neurotoxic effects of the drug should also be taken into account for the timely initiation of therapy.