Levamisole引起多發性炎性腦白質病變：病例報告

Levamisole-induced Multifocal Inflammatory Leukoencephalopathy: A Case Report

吳爵宏(Chueh-Hung Wu) ； 盧璐(Lu Lu)

《台灣復健醫學雜誌》 36卷4期 (2008/12) Pp. 235-240

https://doi.org/10.6315/2008.36(4)05

摘要

Levamisole長久以來被當做驅蟲藥物，後來由於其調節免疫的作用，被使用在治療復發性口腔潰瘍、尋常型天皰瘡、惡性黑色素癌及和5-fluorouracil併用治療大腸癌。然而，已有證據顯示，levamisole可能會引起多發性炎性腦白質病變。Levamisole引起多發性炎性腦白質病變之致病機轉尚未確定，一般認爲是由於levamisole使T細胞和巨噬細胞活性化，以及其在人類可刺激干擾素和介白素－2 (interleukin-2)之製造，誘發免疫反應使腦部白質去髓鞘化而引起臨床症狀。本病例爲－43歲男性，因人類乳突病毒(human papillomavirus)感染手部長疣，開始接受levamisole治療約一個月後，逐漸產生口齒不清，步態不穩，認知功能變差，以及右側肢體無力的現象。病人並無發燒或其他感染症狀，也無特殊旅遊史。腦脊髓液檢查無異常。腦部磁振造影顯示在兩側腦室旁白質、左額葉白質、右頂葉白質及兩側視丘有多處斑塊。經類固醇脈衝療法、血漿置換術及復健治療後，認知功能、言語障礙、步態不穩及運動功能障礙均有顯著進步，追蹤半年後病人已可獨立行走及上下樓梯。多發性炎性腦白質病變為一極罕見的中樞神經炎性病變，若未及早診斷給予適當治療，易留下永久神經學缺損。由於影像上和多發性硬化症及急性瀰散性腦脊髓炎相似，要診斷levamisole 引起之多發性炎性腦白質病變，仍以正確而詳細的病史詢問最爲重要。本文爲第一次探討使用levamisole治療人類乳突病毒而引起多發性炎性腦白質病變之報告，介紹此類病患的症狀、鑑別診斷，以及藥物和復健治療，並回顧文獻，希望做爲臨床醫師診斷及處理類似病人的參考。

關鍵字

levamisole ； 多發性炎性腦白質病變

並列摘要

Levamisole, which is the L-isomer of tetramisole, has been used as an antihelminthic agent. Due to its immunomodulating property, it has been used to treat recurrent aphthous ulcers, pemphigus vulgaris, and malignant melanoma. It also has been used along with 5-fluorouracil to treat colon cancer. The side effects are mild and include nausea, vomiting, diarrhea and metal taste. However, existing evidence suggests that levamisole can induce multifocal inflammatory leukoencephalopathy. The course of levamisole-induced multifocal inflammatory leukoencephalopathy is monophasic and progressive. Clinical symptoms include gait ataxia, dysarthria, dysphasia, conscious disturbance and weakness of the extremities (from hemiparesis to tetraplegia). The exact mechanism is not clear. In humans, levamisole can activate T cells and macrophages, and induce the production of interferon and interleukin-2. Levamisole may induce atransient autoimmune response, resulting in demyelination of brain white matter. We report the case of a 43-year-old male, who was treated with levamisole for human papillomavirus infection. About 1 month later, he suffered from progressive dysarthria, gait ataxia, cognitive impairment and right hemiparesis. There was no evidence of antecedent infection and specific travel history. Examinations of the serum and cerebrospinal fluid showed no abnormal findings. Brain magnetic resonance image (MRI) showed multiple lesions in the bilateral paraventricular white matter, left frontal white matter, right parietal white matter and bilateral thalamus. The patient received pulse therapy with steroids, plasma exchange and rehabilitation. His cognitive impairment, dysarthria, and motor impairment improved greatly. At the6-month follow-up, he was capable of independent level walking and stair climbing. Levamisole-induced multifocal inflammatory leukoencephalopathy is a rare inflammatory disease of the central nervous system. It may lead to permanent neurological deficits if well-timed appropriate treatment is not administered. We discuss the symptoms, differential diagnosis and treatment of this disease. To recognize levamisole-induced multifocal inflammatory leukoencephalopathy, obtaining a detailed historyis most important because it is difficult to differentiate between multifocal inflammatory leukoencephalopathy, multiple sclerosis, and acute disseminated encephalomyelitis based on neuroimaging findings alone.

並列關鍵字

levamisole ； multifocal inflammatory leukoencephalopathy