Prasher Sparsh,  Wigmore Edward,  Surana Snehal,  Vraka Katerina,  Bonney Denise

Final Pr. ID: Poster #: CR-036

Encephalopathy is a well-recognised complication of intrathecal methotrexate in paediatric acute lymphoblastic leukaemia (ALL), often presenting with seizures, altered consciousness, and motor deficits that typically resolve spontaneously within 24–48 hours. In contrast, methotrexate-induced myelopathy is a far rarer and under-recognised entity, with the potential for lasting neurological sequelae if not diagnosed and treated promptly.
We present an unusual case of methotrexate-induced myelopathy in a child with ALL, featuring an atypical clinical presentation and novel MRI findings that expand the recognised radiological phenotype.

A 4-year-old boy in remission from low-risk B-cell ALL (without CNS involvement) received intrathecal and intravenous methotrexate via an atraumatic lumbar puncture. Within hours, he developed left-sided hemiparesis, progressing to quadriparesis, with predominant weakness on the left and brief truncal involvement. He remained afebrile and haemodynamically stable, and laboratory tests, CSF analysis, and methotrexate clearance were all unremarkable. Brain imaging (CT, MRI, MRA) was normal. However, spinal MRI revealed extensive T2 hyperintensity throughout the cervical, thoracic, and lumbar spinal cord, involving both grey and white matter — a pattern more reminiscent of transverse myelitis than classic methotrexate myelopathy. CSF cytology was negative for malignant cells, and autoimmune and infectious screens, including MOG and AQP4 antibodies, were negative. Treatment with high-dose corticosteroids, folinic acid rescue, and IVIG was initiated within 12 hours of symptom onset. The patient showed marked improvement and was discharged ambulant after six weeks, with only mild residual left-sided weakness.

Classic methotrexate myelopathy typically affects the dorsal columns in a caudal-to-rostral progression. In contrast, this case demonstrated diffuse longitudinal cord involvement with mixed grey and white matter changes. Such imaging findings are not widely reported. Histopathological studies in similar cases support a mechanism of superficial demyelination from CSF-contact toxicity, aligning with this radiological presentation.

This case expands the radiological spectrum of methotrexate-induced myelopathy. Recognition of atypical spinal imaging findings is critical for timely diagnosis and early immunomodulatory treatment, which can significantly improve neurological outcomes. Read More

Authors:  Prasher Sparsh , Wigmore Edward , Surana Snehal , Vraka Katerina , Bonney Denise

Keywords:  ALL, Spinal Cord, Pediatric Neuroradiology

Zintsmaster Stephen,  Guzzardo Gianna,  O'hora Kevin

Final Pr. ID: Poster #: CR-012

Neutropenic enterocolitis (NE), commonly referred to as typhlitis (from the Greek typhlos meaning blind / closed) or ileocecal syndrome, is an increasingly common complication of neutropenic pediatric patients, with a reported incidence of 0.8% – 26%. This is especially evident as the use of aggressive chemotherapy regimens in pediatric patients increases. While typically affecting the cecum, other large and small bowel involvement has been described. Symptoms often present within 2 weeks of therapy completion, concurrently with the expected leukocytosis. We present a case of NE with typical and atypical imaging findings.

The patient was a previously healthy 7-year-old male that presented with a two-week history of daily fevers, increased fatigue, abdominal pain, and easy bruising. Flow cytometry confirmed the diagnosis of suspected B-cell Acute Lymphoblastic Leukemia/Lymphoma (ALL) and the patient was started on induction chemotherapy for High Risk ALL. On the patients last day of induction (day 7), the patient began developing worsening lower abdominal pain and bloody stool. Supine radiograph demonstrated a non-specific paucity of gas in abdomen. The patient continued to decline clinically and the physical exam also showed worsening distention with involuntary guarding. A contrast enhanced computed tomography (CT) was ordered which demonstrated NE with significant wall thickening in both the cecum and rectum. Despite ECMO and other heroic efforts the patient expired.

There is one reported case in the available English literature of neutropenic enterocolitis involving the rectum. Our case demonstrates the typical location within the cecum and ascending colon, along with the rarely identified rectal involvement. It is hypothesized that an initial intestinal injury in an already immunocompromised state, allows for an increased inflammatory response and vulnerability to opportunistic bacterial invasion. Based on reports outlining colonic wall thickening in patients with NE seen on ultrasound, there is a reported mortality rate of 60% at 10 mm or greater and only 4.2% at <10 mm. The significant wall thickening present in this case was an ominous sign. However, the lack of adequate research regarding the management NE makes it difficult to create a standardized treatment protocol. This case demonstrates a common and uncommon location of NE within the colon and further demonstrates the importance of early supportive intervention when NE is suspected. Read More

Authors:  Zintsmaster Stephen , Guzzardo Gianna , O'hora Kevin

Keywords:  Neutropenic Enterocolitis, Typhlitis, ALL

Richardson Rebecca,  Morin Cara,  Wheeler Charles,  Karol Seth,  Jeha Sima,  Inaba Hiroto,  Mccarville Beth

Final Pr. ID: Poster #: SCI-019

Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy. Children with ALL are at risk for developing acute pancreatitis (AP) during treatment, most commonly related to asparaginase. According to the American College of Radiology guidelines, ultrasound (US) should be the first line imaging modality in the diagnosis of AP. However, AP in children with ALL is thought to be due to direct pancreatic injury rather than ductal obstruction, and thus US may not be the optimal imaging modality for this diagnosis. Read More

Authors:  Richardson Rebecca , Morin Cara , Wheeler Charles , Karol Seth , Jeha Sima , Inaba Hiroto , Mccarville Beth

Keywords:  pancreatitis, ALL, ultrasound