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Lei CL, Gui XL, Wang LY, Guo YJ, Li Y. Analysis of drug-induced posterior reversible encephalopathy syndrome using the food and drug administration adverse drug events reporting system database. Expert Opin Drug Saf 2024; 23:607-616. [PMID: 38478961 DOI: 10.1080/14740338.2024.2327510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/03/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE In this retrospective pharmacovigilance study, we gathered data on drug-induced posterior reversible encephalopathy syndrome (PRES). Our goal was to identify the primary suspect drugs in PRES by analyzing the Food and Drug Administration Adverse Events Reporting System (FAERS) database. METHODS We identified and analyzed reports of PRES listed in the FAERS database between 2004 and 2021. Using the reporting odds ratio and 95% confidence interval, we evaluated the safety signals for each of the drugs associated with PRES. RESULTS We reviewed 11,077 reports of adverse events corresponding to PRES. The primary suspect drug categories were antineoplastics, immunosuppressants, and glucocorticoids. PRES was 24.77% more likely to occur in females than in males. Drug-induced PRES usually occurs in individuals with cancer, those who have undergone an organ/stem cell transplant, and those with autoimmune conditions. CONCLUSION Our results show that the drugs most commonly suspected to cause PRES were antineoplastics, immunosuppressants, and glucocorticoids. Future studies are needed to illuminate the pathophysiological alterations that underlie PRES. In the meantime, prescribers and patients should be made aware of the potential risks of PRES associated with pharmaceutical therapy, and the summaries of product characteristics for individual drugs should be updated to include this information.
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Affiliation(s)
- Cai-Lu Lei
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
- School of Pharmaceutical Science, Guangxi Medical University, Nanning, China
| | - Xiao-Long Gui
- Department of Gastrointestinal & Gland Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lin-Yu Wang
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
| | - You-Jia Guo
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Yan Li
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
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Lin W, Xie J, Zhang J, Cheng H, Cui H, Zhang Y, Wu Y, Yu J, Qi P, Fan J, Gao H, Wang F, Zhang R, Zheng H. Posterior reversible encephalopathy syndrome in children with acute lymphoblastic leukemia during remission induction chemotherapy: a single-center retrospective study. Minerva Pediatr (Torino) 2023; 75:808-816. [PMID: 31729207 DOI: 10.23736/s2724-5276.19.05675-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND This study investigated the clinical characteristics, cranial magnetic resonance imaging (MRI) features, MRI follow-up, and prognosis of children with acute lymphoblastic leukemia (ALL) who developed posterior reversible encephalopathy syndrome (PRES) during remission induction chemotherapy. METHODS We analyzed the age, gender, PRES symptoms and signs, cranial MRI findings, therapeutic effect, and prognosis of children with ALL who developed PRES during chemotherapy from January 2010 to December 2013 at the Hematology Oncology Center of Beijing Children's Hospital. Changes in cranial MRI findings were analyzed, and intelligence (IQ) and cognitive function were evaluated using the Wechsler Scale and the Wisconsin Card Score Test after the children completed chemotherapy. RESULTS There were 850 children with newly diagnosed ALL in this period; 13 (1.5%), 6 boys and 7 girls, developed PRES. All were diagnosed as B-cell ALL. The median age at PRES onset was 7 years (2-11 years). The median day of PRES onset was day 28 (day 17-34) of remission induction chemotherapy. Of the 13 children with PRES onset and seizures, 4 had visual disturbances and 2 had consciousness disturbances. Cranial MRI showed hyperintensity in the subcortical white matter on T2-weighted axial and fluid-attenuated inversion recovery (FLAIR) images. The lesion locations were as follows: occipital lobe, 12 (92.3%) patients; frontal lobe, 7 (53.8%) patients; temporal lobe, 5 (38.4%) patients; parietal lobe, 3 (23.1%) patients; and cerebellum, 1 (7.7%) patient. There were 8 (61.5%) patients with vasogenic edema and 5 (38.5%) with cytotoxic edema. After treatment, all children recovered within one month, when their PRES symptoms were relieved, they continued to receive chemotherapy. However, 1 child (1.07%) died of severe central nervous system infection one year after PRES treatment, and 3 (25%) had recurrent seizures and were diagnosed with epilepsy after three months of PRES treatment. Their cranial MRIs showed cytotoxic edema, which was acute stage on day 15, with aggravated lesions on cranial MRI. The cranial MRI lesions returned to normal at one month in 3 (23.1%) patients, at three months in 6 (46.1%) patients, at one year in 8 (61.5%) patients, and at two years in 12 (92.3%) patients. The 12 surviving children all returned to school, and their full-scale, verbal, and performance IQs were normal, with no significant differences in intelligence or cognitive function compared with children with ALL without PRES during the same period. CONCLUSIONS PRES can occur during remission induction chemotherapy treatment of children with ALL, but the incidence is low. Cranial MRI can be used for diagnosis and to characterize lesions. The children recover about a month after treatment, and cranial MRI lesions return to normal within two years. The time for complete resolution of MRI lesions differs, and children with cytotoxic edema have worse prognosis with sequelae, such as epilepsy, which requires close monitoring. PRES does not affect intelligence or cognitive development.
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Affiliation(s)
- Wei Lin
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jing Xie
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jishui Zhang
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Hua Cheng
- Imaging Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Haijing Cui
- Intelligence Laboratory, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yuanyuan Zhang
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Ying Wu
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jiaole Yu
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Peijing Qi
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jia Fan
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Huifang Gao
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Fang Wang
- Department of Psychiatry, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Ruidong Zhang
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Huyong Zheng
- Hematology Oncology Center, Beijing Children's Hospital, Capital Medical University, Beijing, China -
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Shrivastava AK, Bodhey NK, Patial Y, Pati SK. Posterior Reversible Encephalopathy Syndrome in the Immediate Postoperative Period of Gastric Cancer. Cureus 2023; 15:e49388. [PMID: 38146571 PMCID: PMC10749695 DOI: 10.7759/cureus.49388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/27/2023] Open
Abstract
A 55-year-old female was referred to the Department of Ophthalmology with complaints of bilateral loss of vision. She had undergone subtotal gastrectomy with gastrojejunostomy and lymphadenectomy for poorly differentiated gastric adenocarcinoma in the antropyloric region the day before. On the first postoperative day, she complained of generalised weakness, drowsiness, altered sensorium, and acute, painless, bilateral loss of vision. Ocular examination revealed visual acuity as no perception of light, bilaterally, and normal pupillary light reflexes. Anterior and posterior segment examination was within normal limits. This clinical presentation of altered sensorium and cortical blindness along with characteristic radiological findings (hyperintensity on T2/fluid-attenuated inversion recovery sequence involving the bilateral parieto-occipital lobe extending in asymmetric fashion to the bilateral cerebellum, brainstem, and thalami predominantly involving the white matter with few areas of diffusion restriction on diffusion-weighted imaging sequence predominantly on the left side with gyriform pattern) confirmed the diagnosis of posterior reversible encephalopathy syndrome (PRES). In cancer patients, PRES has been reported in patients on chemotherapy regimen or two weeks after surgery for gastric cancer. Here, we want to draw attention to the fact that PRES may develop in the immediate postoperative period of gastric cancer surgery, as seen in our case.
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Affiliation(s)
| | | | - Yamini Patial
- Ophthalmology, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Saroj K Pati
- Radiodiagnosis, All India Institute of Medical Sciences, Raipur, Raipur, IND
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Kamińska K, Cudnoch-Jędrzejewska A. A Review on the Neurotoxic Effects of Doxorubicin. Neurotox Res 2023; 41:383-397. [PMID: 37351828 PMCID: PMC10499694 DOI: 10.1007/s12640-023-00652-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 05/15/2023] [Accepted: 05/24/2023] [Indexed: 06/24/2023]
Abstract
Anthracyclines, a class of drugs considered as most effective anticancer drugs, used in the various regimens of cancer chemotherapy, induce long-term impairment of mitochondrial respiration, increase reactive oxygen species, and induce other mechanisms potentially leading to neurotoxicity. According to literature findings, one drug of this class - doxorubicin used to treat e.g. breast cancer, bladder cancer, lymphoma, and acute lymphocytic leukemia may induce such effects in the nervous system. Doxorubicin has poor penetration into the brain due to the lack of drug penetration through the blood-brain barrier, thus the toxicity of this agent is the result of its peripheral action. This action is manifested by cognitive impairment and anatomical changes in the brain and peripheral nervous system found in both preclinical and clinical studies in adult patients. Furthermore, more than 50% of children with cancer are treated with anthracyclines including doxorubicin, which may affect their nervous system, and lead to lifelong damage in many areas of their life. Despite ongoing research into the side effects of this drug, the mechanism of its neurotoxicity action on the central and peripheral nervous system is still not well understood. This review aims to summarize the neurotoxic effects of doxorubicin in preclinical (in vitro and in vivo) research and in clinical studies. Furthermore, it discusses the possible mechanisms of the toxic action of this agent on the nervous system.
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Affiliation(s)
- Katarzyna Kamińska
- Chair and Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Banacha 1b, 02-097, Warsaw, Poland.
| | - Agnieszka Cudnoch-Jędrzejewska
- Chair and Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Banacha 1b, 02-097, Warsaw, Poland
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Li Y, Song J, Huq AM, Timilsina S, Gershwin ME. Posterior reversible encephalopathy syndrome and autoimmunity. Autoimmun Rev 2023; 22:103239. [PMID: 36464226 DOI: 10.1016/j.autrev.2022.103239] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical syndrome characterized by acute or subacute onset of neurological symptoms (e.g., headache, seizure, confusion, vomiting, and diminished eyesight) and impaired endothelial barrier function of the cerebral circulation that leads to bilateral subcortical vasogenic edema, while exhibiting a "reversible" feature in most cases. Clinically, various predisposing or precipitating conditions have been identified, such as hypertension, autoimmune diseases, renal dysfunction/failure, preeclampsia/eclampsia, post-transplantation conditions, and certain therapeutic agents. Among several putative mechanisms, the immune activation hypothesis prevails, as up to 50% of patients with PRES harbor abnormalities related to autoimmunity, such as concurrent systemic lupus erythematosus. In this Review, we summarize the clinical and laboratory evidence that places PRES in the context of autoimmunity.
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Affiliation(s)
- Yang Li
- Department of Critical Care Medicine, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China
| | - Junmin Song
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, PR China.
| | - Ahm M Huq
- Department of Pediatrics, Central Michigan University, Detroit, MI 48201, USA
| | - Suraj Timilsina
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616, USA
| | - M Eric Gershwin
- Division of Rheumatology/Allergy and Clinical Immunology, School of Medicine, University of California, Davis, CA 95616, USA
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Shash H, Aldaama S, Omer H, Alafghani S. Different Clinicoradiological Characteristics of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncology and Post-Bone Marrow Transplantation Cases: A Retrospective Study. Front Neurol 2022; 13:836033. [PMID: 35599741 PMCID: PMC9120546 DOI: 10.3389/fneur.2022.836033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is receiving increasing recognition in pediatrics. However, comparisons between PRES in pediatric oncology and post-bone marrow transplantation (BMT) are lacking. Therefore, we aimed to describe the risk factors and clinical and radiological features of PRES and investigate the differences between PRES in pediatric oncology and post-BMT. The PRES data of 13 patients from our center were combined with those of 217 cases from the PubMed, Scopus, and Web of Science databases. The patients were divided into either an oncology or a post-BMT group. We included 230 patients in the analysis, 26.1% of whom belonged to the post-BMT group. Oncology patients developed PRES at a younger age (p = 0.010) and were more likely to develop encephalopathy (p = 0.004). Systemic hypertension (S-HTN) preceding PRES occurred in 43.5% (66/154) of patients. Post-BMT patients were more likely to have S-HTN (p = 0.003). Cyclosporine levels were detected in 37 patients; 40.5% had supra-therapeutic levels. The radiological findings were atypical in 74.3% of patients, and delayed repeated imaging increased the occurrence of resolution (p = 0.004). Sixteen (7%) patients developed PRES recurrence after a median of 8 weeks, with the between-group difference being non-significant. Oncology patients were more likely to develop chronic epilepsy, while BMT patients were more likely to develop rare neurologic abnormalities (p < 0.001). In conclusion, atypical clinical presentation and imaging findings should not hinder the diagnosis of PRES. S-HTN is a risk factor, particularly in post-BMT patients. Supra-therapeutic levels of cyclosporine and previous exposure to immunosuppression did not increase the risk of recurrence.
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Affiliation(s)
- Hwazen Shash
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahad Hospital of the University, Al-Khobar, Saudi Arabia
- *Correspondence: Hwazen Shash ; orcid.org/0000-0002-4128-9504
| | - Saad Aldaama
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Hala Omer
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Sameera Alafghani
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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Posterior reversible encephalopathy syndrome (PRES) due to acute hypertension in children: 12 years single-center experience. Acta Neurol Belg 2021; 121:1583-1589. [PMID: 32632712 DOI: 10.1007/s13760-020-01423-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 06/29/2020] [Indexed: 12/26/2022]
Abstract
The objective of the study is to evaluate the clinical and neuroradiological findings, the risk factors for recurrence and the prognosis in patients with posterior reversible encephalopathy syndrome developed secondary to acute hypertension in children. The study was conducted between 2008 and 2019 at Mersin University Faculty of Medicine. A total of 49 episodes were evaluated retrospectively in 38 patients with PRES secondary to acute hypertension. The demographic data, etiology, and clinical and neuroradiological findings were recorded. Twenty-one (55.3%) patients were female; the mean age was 11.8 years. The etiology of acute hypertension in 29 (76.3%) patients was end-stage renal disease (ESRD). The most common clinical findings were seizure (81.6%) and altered consciousness (79.6%). Status epilepticus developed in eight (16.3%) episodes. MRI lesions were atypical in 33 episodes (67.3%). In eight (21%) patients, PRES recurred. Irreversible brain damage was detected after PRES in three (7.8%) patients. C-reactive protein and erythrocyte sedimentation rate were elevated in 82.2% and 71.4% of the episodes, respectively. A statistically significant relationship was found between the recurrence, the duration of hospitalization at the PICU, SE and the occurrence of irreversible lesion (p = 0.013, p = 0.015, p = 0.001 respectively). Also, there were statistically significant relationships between recurrence and ESRD; epilepsy and recurrences; SE and irreversible brain damage (p = 0.02, p = 0.012, p = 0.025 respectively). Although PRES is usually known to have a good prognosis, the mortality and morbidity rates may increase in the long-term follow-up as in our study. In this study, the etiology, the presence of status epilepticus, PICU history, atypical MRI lesions and increased inflammatory markers were found to be important for the prognosis in PRES.
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Abdou MAA, El Kiki HA, Madney Y, Youssef AA. Chemotherapy-related neurotoxicity in pediatric cancer patients: magnetic resonance imaging and clinical correlation. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021. [DOI: 10.1186/s43055-021-00606-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Cancer is the second most common cause of death among children aged 1–14 years in the USA. Pediatric malignancies have elevated morbidity and mortality in the absence of proper treatment. Intensive treatment regimens have resulted in a significant increase in the number of survivors but also have been associated with the risk of developing neurotoxicity. The purpose of this study is to emphasize the role of advanced MRI techniques in the early detection of different chemotherapy neurotoxicities and make radiologists aware of them providing early management to prevent permanent damage.
Results
We evaluated 63 patients (43 males and 20 females), and their ages ranged from (2 to 17 years) with suspected chemotherapy-related neurotoxicity. MR examinations were performed with 1.5-T Philips systems. Clinical data were correlated with magnetic resonance imaging (MRI), and different treatment complications were diagnosed. All of our 63 patients were receiving chemotherapy treatment, and they developed different neurological symptoms. Patients diagnosed as posterior reversible encephalopathy syndrome were 41 with 8 patients had typical and 33 had atypical criteria, 16 patients diagnosed as cerebral venous sinus thrombosis with magnetic resonance venography (MRV) are the most important sequence that successfully diagnosed them, and finally, 6 patients diagnosed as methotrexate neurotoxicity with diffusion-weighted images (DWI) are the most important sequence for early diagnosis.
Conclusion
Chemotherapy is associated with certain neurotoxicities, conventional MRI can detect them, but by the use of advanced MRI techniques including MRV and DWI early detection of these neurotoxicities can occur. Therefore, the combination of conventional MRI together with advanced techniques improves the diagnostic efficacy of MRI in the early diagnosis of neurotoxicity.
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Mergen S, Long B, Matlock A. Posterior Reversible Encephalopathy Syndrome: A Narrative Review for Emergency Clinicians. J Emerg Med 2021; 61:666-673. [PMID: 34696929 DOI: 10.1016/j.jemermed.2021.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic disorder characterized by seizures, headache, altered mental status, and visual disturbances, and is often associated with acute hypertension. OBJECTIVE This narrative review provides a focused description of the presentation, diagnostic evaluation, and management of PRES. DISCUSSION PRES is associated with a variety of factors, including acute rise in blood pressure, renal disease, preeclampsia/eclampsia, and immunosuppressive therapy. The pathophysiology is theorized to involve dysfunction of cerebral autoregulation leading to vascular leak or endothelial dysfunction resulting in vasogenic edema. In the emergency department (ED), clinical findings suggestive of PRES should prompt diagnostic testing focused on confirming the diagnosis and excluding other conditions that may present similarly. Laboratory studies are primarily useful for excluding alternative diagnoses. Computed tomography (CT) and, in particular, magnetic resonance imaging (MRI) are the recommended neuroimaging modalities for diagnosis. CT and MRI may demonstrate cerebral vasogenic edema, most often in the distribution of the posterior circulation. Treatment involves management of seizures, control of blood pressure if elevated, and treatment of any underlying trigger. CONCLUSION PRES is a neurological disorder that is typically reversible if recognized on presentation and promptly and appropriately managed. This narrative review characterizes this condition for emergency clinicians.
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Affiliation(s)
- Stephanie Mergen
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Aaron Matlock
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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Rijmenams I, Moechars D, Uyttebroeck A, Radwan A, Blommaert J, Deprez S, Sunaert S, Segers H, Gillebert CR, Lemiere J, Sleurs C. Age- and Intravenous Methotrexate-Associated Leukoencephalopathy and Its Neurological Impact in Pediatric Patients with Lymphoblastic Leukemia. Cancers (Basel) 2021; 13:cancers13081939. [PMID: 33923795 PMCID: PMC8073318 DOI: 10.3390/cancers13081939] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 12/04/2022] Open
Abstract
Simple Summary In this study, we investigated standardized post-chemotherapy magnetic resonance (MR) scans for leukoencephalopathy and patient- and treatment-related risk factors in childhood leukemia patients. As prevalence numbers are limited, our study provides the required estimations for this population. Furthermore, we demonstrate that younger patients might be more at-risk for development of leukoencephalopathy (LE), and that a higher intravenous methotrexate (IV-MTX) dose has a cumulative toxic effect, while the number of intrathecal administrations was not significantly associated with the extent of LE. This can suggest we should modify chemotherapeutic treatment regimens by decreasing the number of IV-MTX applications, with special attention for younger patients. Abstract Methotrexate (MTX) is associated with leukoencephalopathy (LE) in children treated for lymphoblastic leukemia/lymphoma (ALL/LBL). However, large-scale studies with systematic MR acquisition and quantitative volumetric lesion information remain limited. Hence, the prevalence of lesion burdens and the potential risk factors of LE in this population are still inconclusive. FLAIR-MRI scans were acquired at the end of treatment in children who were treated for ALL/LBL, which were quantitatively analyzed for LE. Voxels were assigned to the lesion segmentation if indicated by two raters. Logistic and linear regression models were used to test whether lesion presence and size were predicted by risk factors such as age at diagnosis, gender, intrathecal (IT-) or intravenous (IV-)MTX dose, CNS invasion, and acute neurological events. Patients with a pre-existing neurological condition or low-quality MR scan were excluded from the analyses. Of the 129 patients, ten (8%) suffered from CNS invasion. Chemotherapy-associated neurological events were observed in 13 patients (10%) during therapy, and 68 patients (53%) showed LE post-treatment. LE was more frequent in cases of lower age and higher cumulative IV-MTX doses, while the extent of LE and neurological symptoms were associated only with IV-MTX doses. Neurological events were not significantly associated with LE, even though symptomatic patients demonstrated a higher ratio of LE (n = 9/13) than asymptomatic patients (n = 59/116). This study suggests leukoencephalopathy frequently occurs in both symptomatic and asymptomatic leukemia patients. Younger children and patients treated with higher cumulative IV-MTX doses might need more regular screening for early detection and follow-up of associated sequelae.
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Affiliation(s)
- Ilona Rijmenams
- Department of Brain and Cognition, KU Leuven, 3000 Leuven, Belgium; (I.R.); (D.M.); (C.R.G.)
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
| | - Daan Moechars
- Department of Brain and Cognition, KU Leuven, 3000 Leuven, Belgium; (I.R.); (D.M.); (C.R.G.)
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
| | - Anne Uyttebroeck
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
| | - Ahmed Radwan
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Jeroen Blommaert
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Gynaecological Oncology, KU Leuven, 3000 Leuven, Belgium
| | - Sabine Deprez
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Stefan Sunaert
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Heidi Segers
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
| | - Céline R. Gillebert
- Department of Brain and Cognition, KU Leuven, 3000 Leuven, Belgium; (I.R.); (D.M.); (C.R.G.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
| | - Jurgen Lemiere
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, 3000 Leuven, Belgium;
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
| | - Charlotte Sleurs
- Department of Pediatric Oncology, KU Leuven, 3000 Leuven, Belgium; (A.U.); (H.S.)
- Leuven Cancer Institute, KU Leuven, 3000 Leuven, Belgium; (A.R.); (J.B.); (S.D.); (S.S.)
- Leuven Brain Institute, KU Leuven, 3000 Leuven, Belgium
- Correspondence:
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Alshami A, Al-Bayati A, Douedi S, Hossain MA, Patel S, Asif A. Clinical characteristics and outcomes of patients admitted to hospitals for posterior reversible encephalopathy syndrome: a retrospective cohort study. BMC Neurol 2021; 21:107. [PMID: 33750332 PMCID: PMC7941613 DOI: 10.1186/s12883-021-02143-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/26/2021] [Indexed: 11/25/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) is usually a benign, yet underdiagnosed clinical condition associated with subacute to acute neurological manifestations primarily affecting white matter. PRES is reversible when recognized promptly and treated early by removal of the insulting factor; however, can lead to irreversible and life-threatening complications such as cerebral hemorrhage, cerebellar herniation, and refractory status epilepticus. Methods We utilized the National Inpatient Sample database provided by the Healthcare Cost and Utilization Project (HCUP-NIS) 2017 to investigate the demographic variables (age, sex, and race) for patients with PRES, concomitant comorbidities and conditions, inpatient complications, inpatient mortality, length of stay (LOS), and disposition. Results A total of 635 admissions for patients aged 18 years or older with PRES were identified. The mean age was 57.2 ± 0.6 years old with most encounters for female patients (71.7%, n = 455) and white as the most prevalent race. Half the patients in our study presented with seizures (50.1%, n = 318), sixty-three patients (9.9%) presented with vision loss, and sixty-four patients (10.1%) had speech difficulty. In addition, 45.5% of patients had hypertensive crisis (n = 289). 2.2% of hospitalizations had death as the outcome (n = 14). The mean LOS was 8.2 (±0.3) days, and the mean total charges were $92,503 (±$5758). Inpatient mortality differed between males and females (1.7% vs. 2.4%) and by race (3.6% in black vs. 1.8% in white) but was ultimately determined to be not statistically significant. Most patients who present with vision disturbance have a high risk of intracranial hemorrhage. Furthermore, end-stage renal disease, atrial fibrillation, and malignancy seemed to be linked with a very high risk of mortality. Conclusion PRES, formerly known as reversible posterior leukoencephalopathy, is a neurological disorder with variable presenting symptoms. Although it is generally a reversible condition, some patients suffer significant morbidity and even mortality. To the best of our knowledge, this is the largest retrospective cohort of PRES admissions that raises clinician awareness of clinical characteristics and outcomes of this syndrome.
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Affiliation(s)
- Abbas Alshami
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Asseel Al-Bayati
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Steven Douedi
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, 07753, USA.
| | - Mohammad A Hossain
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Swapnil Patel
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
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Hafez HA, Ragab I, Sedky M, Shams M, Youssef A, Refaat A, Habib E, Sidhom I. Patterns, risk factors and outcome predictors of posterior reversible encephalopathy syndrome in pediatric cancer patients. Leuk Lymphoma 2020; 62:462-468. [PMID: 33063564 DOI: 10.1080/10428194.2020.1832658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The purpose of this study was to assess the clinical and radiological patterns and outcome predictors of posterior reversible encephalopathy syndrome (PRES) in pediatric cancer patients. A retrospective study included patients who developed PRES during their treatment at the Children's Cancer Hospital Egypt. A total of 50 patients developed PRES. Leukemia and lymphoma were the commonest diagnoses (64%). Regarding the MRI findings, occipital affection was the most common (92%), followed by frontal and temporal lobes involvement in 32% and 22% respectively and advanced PRES was described in 8 patients. Of the whole patients, 80% had complete clinical resolution and 60% showed complete radiological resolution at 2 weeks' evaluation and 2 patients died out of PRES. Unfavorable outcome was associated with those who had motor dysfunction, status epilepticus at presentation, frontal lobe and thalamic affection and atypical PRES. PRES might present in atypical sites with poor outcome including death.
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Affiliation(s)
- Hanafy A Hafez
- Department of Pediatric Oncology, National Cancer institute, Cairo University, Cairo, Egypt.,Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Iman Ragab
- Pediatric Department, Hematology-Oncology Unit, Ain Shams University, Cairo, Egypt
| | - Mohamed Sedky
- Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Marwa Shams
- Pediatric Department, Hematology-Oncology Unit, Ain Shams University, Cairo, Egypt
| | - Ayda Youssef
- Radiology Department, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Amal Refaat
- Radiology Department, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Elsaeed Habib
- Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt.,Pediatric Department, Hematology-Oncology Unit, Ain Shams University, Cairo, Egypt
| | - Iman Sidhom
- Department of Pediatric Oncology, National Cancer institute, Cairo University, Cairo, Egypt.,Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt
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13
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Schroyen G, Meylaers M, Deprez S, Blommaert J, Smeets A, Jacobs S, Sunaert S, Sleurs C, Uyttebroeck A. Prevalence of leukoencephalopathy and its potential cognitive sequelae in cancer patients. J Chemother 2020; 32:327-343. [PMID: 32799637 DOI: 10.1080/1120009x.2020.1805239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Due to the rising use of chemotherapy treatment in cancer patients and growing survival rates, therapy-induced neurotoxic side effects are increasingly reported. Given the ambiguity about the prevalence and severity of leukoencephalopathy, one of such toxic side effects, in non-central nervous system (CNS) cancer patients, we performed a systematic literature search using the PubMed/Medline database to summarize existing literature regarding leukoencephalopathy epidemiology in non-CNS cancer patients and its potential cognitive sequelae. The search was based on the following terms: ('MRI' OR 'T2-weighted MRI' OR 'FLAIR') AND ('cancer' OR 'tumour' OR 'leukaemia' OR 'neoplasms') AND ('chemotherapy' OR 'radiotherapy') AND ('posterior reversible encephalopathy' OR 'leukoencephalopathy' OR 'cerebral ischaemia' OR 'stroke'). Thirty-two studies discussing the occurrence of leukoencephalopathy in cancer patients were included, of which the majority investigated Acute Lymphoblastic Leukaemia (ALL) patients (n = 22).Regularly scanned ALL patients showed a prevalence of leukoencephalopathy between 17 - 87%, and 15 - 83% of patients presented with leukoencephalopathy when only scanned after a CNS event. When diagnosed with posterior reversible encephalopathy syndrome, 100% of patients showed leukoencephalopathy because its diagnosis is based in part on observable lesions. An increased prevalence was observed in ALL patients treated with higher doses of methotrexate (5 g/m2 MTX, 42 - 87%) when compared to lower doses (< 5 g/m2, 32 - 67%). By contrast, in breast cancer patients, white matter lesions were mainly detected in case of neurological symptoms, but not (yet) clearly associated with chemotherapy administration. However, chemotherapy treatment was associated with more infratentorial microbleeds in breast cancer patients . Up to 50% of other (neurologically asymptomatic) solid tumour patients presented white matter lesions, even years after treatment. When cognitive data were investigated, lesioned patients showed lower scores on neurocognitive tests in 50% of studies, years after ending therapy.In conclusion, leukoencephalopathy is well-documented for ALL patients (with a focus on methotrexate), but there is a lack of knowledge for other intravenous chemotherapeutics, other oncological populations, wider age ranges and possible risk factors (e.g. history of CNS event). Furthermore, the long-term neuropsychological impact and potential risk for neurodegenerative processes due to leukoencephalopathy remains inconclusive. Hence, large international databanks, epidemiological and prospective case-control studies are necessary to stratify risk groups for CNS-related side effects.
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Affiliation(s)
- Gwen Schroyen
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | | | - Sabine Deprez
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | | | - Ann Smeets
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Surgical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Sandra Jacobs
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Pediatric Hemato-Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Stefan Sunaert
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Radiology University Hospitals Leuven, Leuven, Belgium
| | - Charlotte Sleurs
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Pediatric Hemato-Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Anne Uyttebroeck
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of Pediatric Hemato-Oncology, University Hospitals Leuven, Leuven, Belgium
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14
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Monti M, Barone D, Amadori E, Bartolini G, Ruscelli S, Frassineti GL. Posterior reversible encephalopathy syndrome: A rare neurotoxicity after capecitabine. J Oncol Pharm Pract 2020; 26:1795-1801. [PMID: 32312144 DOI: 10.1177/1078155220914704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a condition characterized by seizures, headache, visual disturbances, paresis, nausea and altered mental status. Risk factors include hypertension, eclampsia/pre-eclampsia, infection/sepsis, transplantation (allograft, bone marrow and solid organ) and immunosuppression, especially in association with autoimmune disorders and use of cyclosporine or chemotherapy. CASE REPORT A few days after starting the first cycle of treatment with capecitabine, a 50-year-old female with metastatic breast cancer experienced serious adverse events consisting of severe hematological, gastrointestinal and neurological toxicity. A brain magnetic resonance imaging, performed because of the severe state of confusion of the patient, confirmed PRES. MANAGEMENT AND OUTCOME The patient was admitted to the hospital; capecitabine was stopped and treatment was started with antibiotics, growth factor therapy and blood and platelet transfusions. Her clinical conditions slowly improved and the PRES resolved. A dihydropyrimidine dehydrogenase deficiency was identified. DISCUSSION The patient had previously been treated with another fluoropyrimidine, 5-fluorouracil, but without toxicity. A literature search was performed, and only six cases of PRES associated with capecitabine were found. Our case suggests that capecitabine differs from 5-fluorouracil in its mechanism of action and that at least one of the metabolites of capecitabine has the ability to cross the blood-brain barrier, causing neurotoxicity. We believe that it is useful to test for dihydropyrimidine dehydrogenase deficiency before using fluoropyrimidines and would encourage the reporting of such cases of PRES to gain a better overall picture of its incidence in this setting. NARANJO SCORE 7.
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Affiliation(s)
- Manlio Monti
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Domenico Barone
- Radiology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Elena Amadori
- Radiology Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Giulia Bartolini
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Silvia Ruscelli
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Giovanni Luca Frassineti
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
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15
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Cerebral HSV-1 Vasculitis as a Fatal Complication of Immunosuppression in Non-Hodgkin´s Lymphoma: A Case Report and Review of the Literature. Pathogens 2020; 9:pathogens9030193. [PMID: 32151046 PMCID: PMC7157652 DOI: 10.3390/pathogens9030193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 11/17/2022] Open
Abstract
Patients with lymphoma are predisposed to infection because of the immunocompromised state related to the disease itself and as a consequence of chemo-/radiotherapy. Here, we report a case of Herpes-simplex virus encephalitis (HSE) in an immunosuppressed patient with splenic marginal zone lymphoma (SMZL), a rare indolent variant of non-Hodgkin´s lymphoma (NHL). The course was complicated febrile neutropenia and HSV-1-related cerebral vasculitis causing progressive ischemic stroke. This case illustrates the expanding spectrum of atypical clinical and radiological manifestations of HSE in patients treated with myelotoxic drugs. Moreover, we summarize the few central nervous system manifestations of SMZL reported in the literature and discuss distinct causes of neurological deterioration in patients with NHL.
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16
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Gil I, Serrazina F, Pinto M, Viana-Baptista M. Posterior reversible encephalopathy syndrome associated with the use of chemotherapeutic agents: a rare complication after treatment with vinorelbine. BMJ Case Rep 2020; 13:13/2/e229319. [PMID: 32066575 DOI: 10.1136/bcr-2019-229319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological syndrome characterised by a combination of headache, encephalopathy, seizures and visual disturbances, associated with high-intensity abnormalities on T2-weighted images affecting subcortical white and grey matter of the occipital and parietal lobes. Among other causes, PRES has been associated with the use of several medications including chemotherapeutic agents. Here we report a case of a 65-year-old patient with squamous cell carcinoma of the lung treated with cisplatin/vinorelbine. Following the second administration of vinorelbine, she was admitted to the hospital for a generalised seizure. Blood pressure was just slightly elevated and, except for drowsiness, she had a near-normal neurological examination. MRI corroborated the diagnosis. Vinorelbine-induced PRES has been reported only once in the literature, also in association with cisplatin. Our case underlines the role of vinorelbine and suggests that its association with cisplatin in this setting may enhance the risk of PRES.
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Affiliation(s)
- Ines Gil
- Neurorradiology, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal
| | - Filipa Serrazina
- Neurology, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal
| | - Miguel Pinto
- Neurology, Centro Hospitalar de Lisboa Ocidental EPE, Lisboa, Portugal
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17
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Cacho-Díaz B, Lorenzana-Mendoza NA, Salmerón-Moreno K, Reyes-Soto G, Castillo-Rangel C, Corona-Cedillo R, Escobar-Ceballos S, de la Garza-Salazar JG. Chemotherapy-induced posterior reversible encephalopathy syndrome: Three case reports. Medicine (Baltimore) 2019; 98:e15691. [PMID: 31083272 PMCID: PMC6531111 DOI: 10.1097/md.0000000000015691] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
RATIONALE Posterior reversible encephalopathy syndrome (PRES) has been associated with the use of several medications, including chemotherapeutic agents. PATIENT CONCERNS A 65-year-old woman was diagnosed with adenocarcinoma of the ovary, after sixth-line treatment with topotecan, at the beginning of the fourth cycle, she was admitted to the emergency room for presenting tonic-clonic seizures, visual disturbance, and hypertension. A 66-year-old woman was diagnosed with bilateral breast cancer; due to disease progression, treatment with paclitaxel and gemcitabine was started, 1 month after the last dose of chemotherapy, she was admitted to the emergency room for suffering severe headache, altered mental status, tonic-clonic seizures, and hypertension. A 60-year-old patient diagnosed with breast cancer on the left side, underwent second-line chemotherapy with gemcitabine, carboplatin, and bevacizumab, and 1 month after the last dose of chemotherapy, she was also admitted to the emergency room due to altered mental status, vomiting, tonic-clonic seizures, and hypertension. DIAGNOSIS They were diagnosed as PRES based on physical examination, laboratory findings, and imaging techniques that revealed diffuse lesions and edema within the parieto-occipital regions. INTERVENTIONS They received support treatment with blood pressure (BP) control, seizures were controlled with a single anti-epileptic agent, and chemotherapeutic agents from the onset of PRES to its resolution were discontinued. OUTCOMES All these patients improved after medical treatment was started. LESSONS Medical personnel and therapeutic establishments need to be made aware about this chemotherapy-induced neurologic complication.
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18
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Malkan UY, Gunes G, Demiroglu H, Goker H. Immunosuppression-associated posterior reversible encephalopathy syndrome in an acute leukemia case. Hematol Rep 2018; 10:7257. [PMID: 30542527 PMCID: PMC6240836 DOI: 10.4081/hr.2018.7257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 05/02/2018] [Indexed: 11/25/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) was described in 1996. Herein, we aimed to report an immunosuppression- related PRES case. A 34-year-old woman was diagnosed as t-cell acute lymphoblastic leukemia and allogeneic hematopoietic stem cell transplantation (HSCT) was performed. Cyclosporine was given for GVHD prophylaxis in addition to the other routine medications of HSCT. She was hospitalized for acute renal failure and due to the possible contribution of acute renal failure cyclosporine was stopped. Tacrolimus was started for GVHD prophylaxis at a dose of 1 mg/day. However, fifteen days after the initiation of tacrolimus, blurred vision occurred in our patient. Petechial bleeding sites were detected in bilateral cerebral and cerebellar hemisphere by MR imaging. Tacrolimus dosage was reduced to 0.5 mg/day. She had hypertension which was difficult to control and followed-up in the intensive care unit. She had seizures. Control cranial MR resulted as diffusion limitation in bilateral cerebellar hemisphere, bilateral occipital and frontal-parietal regions with vasogenic edema findings; contrast involvement in left frontal-parietal and right cerebellar regions. She had vision loss and lethargy. Control cranial MR favored PRES syndrome secondary to immunosuppression. Hypertensive state was taken under control with antihypertensive treatment and all immunosuppressive agents were stopped. Two weeks later her clinical condition was slightly improved. MR test which was conducted 2 weeks after the diagnosis revealed the regression of PRES lesions. The characteristic signs on neuroimaging are the symmetrical white matter edema in the posterior cerebral hemispheres, particularly the parietal- occipital regions. In conclusion, PRES rarely develops secondary to the immunosuppressive agents and the clinicians should suspect and promptly diagnose PRES which might cause otherwise serious irreversible clinical complications.
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Affiliation(s)
- Umit Y Malkan
- Department of Hematology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Gursel Gunes
- Department of Hematology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Haluk Demiroglu
- Department of Hematology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Hakan Goker
- Department of Hematology, Hacettepe University School of Medicine, Ankara, Turkey
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Smets GJ, Loyson T, Van Paesschen W, Demaerel P, Nackaerts K. Posterior reversible encephalopathy syndrome possibly induced by pemetrexed maintenance therapy for lung cancer: a case report and literature review. Acta Clin Belg 2018; 73:382-388. [PMID: 29173113 DOI: 10.1080/17843286.2017.1403103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Introduction Advances in systemic chemotherapy, molecular targeted therapy and immunotherapy have extended and improved the quality of life of patients with cancer. However, the central nervous system is very susceptible to complications of systemic cancer and its treatment. Posterior reversible encephalopathy syndrome (PRES) is a rare clinical and neuroradiologic entity which has garnered increasing recognition in the past two decades. Cancer patients are generally treated with cytotoxic agents, immunotherapy, molecular targeted therapies or glucosteroids which are more frequently associated with PRES. Case presentation A 59-year old female, known with a relapse of her lung adenocarcinoma, had been treated with 4 cycles of cisplatin (75 mg/m²) and pemetrexed (500 mg/m²). Six weeks after this combination chemotherapy and within 28 h after the administration of pemetrexed maintenance therapy, she developed a generalised epileptic insult. Magnetic resonance imaging (MRI) of the brain showed bilateral areas of increased signal intensity in the subcortical parietal and frontal white matter. She was treated with a broad spectrum antiseizure drug, levetiracetam 750 mg twice daily and strict control of blood pressure. Discussion Diagnosis of PRES should be considered in all patients with neurologic symptoms who are at risk to develop PRES. It is crucial to establish the diagnosis as soon as possible since there is no specific treatment of PRES other than correction of the underlying risk factors and preventing seizure recurrence. Administration of pemetrexed is a possible risk factor for the development of PRES.
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Affiliation(s)
- Gert-Jan Smets
- Clinical Department of Pneumology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Tine Loyson
- Clinical Department of Oncology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Wim Van Paesschen
- Clinical Department of Neurology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Philippe Demaerel
- Clinical Department of Radiology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Kristiaan Nackaerts
- Clinical Department of Pneumology, University Hospitals Leuven, University of Leuven, Leuven, Belgium
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Lifson N, Pasquale A, Salloum G, Alpert S. Ophthalmic Manifestations of Posterior Reversible Encephalopathy Syndrome. Neuroophthalmology 2018; 43:180-184. [PMID: 31312242 DOI: 10.1080/01658107.2018.1506938] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 07/26/2018] [Accepted: 07/28/2018] [Indexed: 10/28/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a condition of neurotoxicity that presents with a sudden onset of symptoms including headache, altered mental status, seizures, and visual disturbances. Monitoring visual symptoms in PRES is critical as visual deficits are found in nearly 40% of patients. This paper aims to identify the visual symptoms associated with PRES and determine visual outcomes following treatment. While the symptoms of PRES are alarming, the disease is typically reversible once the cause is eliminated. Our findings suggest that those who present with ocular complaints can be reassured that their symptoms will improve, if not completely resolve.
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Affiliation(s)
- Nicole Lifson
- Department of Ophthalmology, State University of New York Upstate Medical Center, Syracuse, New York, USA
| | - Andrew Pasquale
- Department of Ophthalmology, State University of New York at Buffalo, Buffalo, New York, USA
| | - George Salloum
- Department of Ophthalmology, State University of New York Upstate Medical Center, Syracuse, New York, USA
| | - Samuel Alpert
- Department of Ophthalmology, State University of New York Upstate Medical Center, Syracuse, New York, USA
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Abstract
PURPOSE OF REVIEW The purpose of this review is to provide a practical clinical approach to confusion in the patient with cancer. Confusion in the cancer population has a broader differential diagnosis than in the general medical population. The clinician must consider the usual differential diagnoses as well as causes unique to the cancer patient including direct complications from the cancer and indirect complications related to cancer treatment. RECENT FINDINGS In the recent age of precision medicine, the oncologist now utilizes the genomic profile of both the patient and the tumor to provide advanced biologic therapies including targeted anticancer drugs, antiangiogenic agents, and immunotherapy. Such advances carry with them an emerging pattern of neurotoxicity which, although less well described in the literature, is now an important consideration to the clinical approach to confusion in cancer patients. SUMMARY Confusion is the most common neurologic complication in cancer and is associated with significant morbidity, mortality, and prolonged hospital stays resulting in increased healthcare costs. Early recognition and treatment of delirium is essential to improve clinical outcomes.
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22
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Gao B, Lyu C, Lerner A, McKinney AM. Controversy of posterior reversible encephalopathy syndrome: what have we learnt in the last 20 years? J Neurol Neurosurg Psychiatry 2018; 89:14-20. [PMID: 28794149 DOI: 10.1136/jnnp-2017-316225] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/03/2017] [Accepted: 07/03/2017] [Indexed: 11/03/2022]
Abstract
Over two decades have passed since posterior reversible encephalopathy syndrome (PRES) was first described in 1996. It has becoming increasingly recognised because of improved and more readily available imaging modality. The exact pathophysiological mechanism is not completely understood and remains controversial at present. Precise diagnosis is essential to guide prompt, proper management. Our ability of differentiating it from other acute neurological disorders is likely to improve as we learnt more about the spectrum of this entity in the last 20 years. We emphasise the importance of recognising its diagnostic criteria and biomarker, which would be of great relevance to either outcome evaluation or study design. PRES has a favourable prognosis generally, but neurological sequelae and even fatalities can occur, especially in severe forms that might cause substantial morbidity and even mortality, particularly when the syndrome is complicated by intracranial haemorrhage or brain infarction. In this review, the pathophysiology, approach to diagnosis, some controversies as to the prognosis, as well as the future research direction of PRES are described.
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Affiliation(s)
- Bo Gao
- Department of Radiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Cui Lyu
- Department of Neurology, Yantaishan Hospital of Yantai City, Yantai, Shandong, China
| | - Alexander Lerner
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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23
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Shah RR. Anti-Angiogenic Tyrosine Kinase Inhibitors and Reversible Posterior Leukoencephalopathy Syndrome: Could Hypomagnesaemia Be the Trigger? Drug Saf 2017; 40:373-386. [PMID: 28181126 DOI: 10.1007/s40264-017-0508-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Reversible posterior leukoencephalopathy syndrome (RPLS), also known frequently as posterior reversible encephalopathy syndrome (PRES), is a characteristic acute neuro-radiology syndrome with clinical presentation that typically includes acute hypertension, seizures and other neurological symptoms and signs. Many patients with RPLS have (a history of) pre-existing hypertension and in receipt of diuretics. It is being diagnosed more frequently and in association with an increasing number of morbidities and medications. Drugs most frequently implicated are immunosuppressant drugs and anticancer agents, including a number of anti-angiogenic tyrosine kinase inhibitors (TKIs). Hypomagnesaemia is a frequent finding at presentation in RPLS patients, which is known to lead to or aggravate hypertension. Pre-eclampsia, a variant of RPLS, responds effectively to intravenous magnesium. Cyclosporin, tacrolimus and some TKIs that induce RPLS are also known to give rise to both hypertension and hypomagnesaemia. This raises an interesting hypothesis that hypomagnesaemia may play a contributory role in triggering RPLS in some patients by acutely raising the blood pressure further. Additional systematic studies are required to test this hypothesis. If the hypothesis is confirmed, hypomagnesaemia offers an effective target for risk mitigation and prevention of RPLS in patients identified at risk.
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Affiliation(s)
- Rashmi R Shah
- Pharmaceutical Consultant, 8 Birchdale, Gerrards Cross, Buckinghamshire, UK.
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24
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Zama D, Gasperini P, Berger M, Petris M, De Pasquale MD, Cesaro S, Guerzoni ME, Mastrodicasa E, Savina F, Ziino O, Kiren V, Muggeo P, Mura RM, Melchionda F, Zanazzo GA. A survey on hematology-oncology pediatric AIEOP centres: The challenge of posterior reversible encephalopathy syndrome. Eur J Haematol 2017; 100:75-82. [PMID: 29032616 DOI: 10.1111/ejh.12984] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Posterior reversible encephalopathy syndrome (PRES) is one of the most common neurological complications in hematology-oncology pediatric patients. Despite an increasingly recognized occurrence, no clear consensus exists regarding how best to manage the syndrome, because most cases of PRES have reported in single-case reports or small series. Aim of this paper is to identify incidence, clinical features, management, and outcome of PRES in a large series of hematology-oncology pediatric patients. METHODS The cases of PRES occurred in twelve centers of the Italian Association of Pediatric Hematology and Oncology were reported. RESULTS One hundred and twenty-four cases of PRES in 112 pediatric patients were recorded with an incidence of 2.1% and 4.7%, respectively, in acute lymphoblastic leukemia in first complete remission and hematopoietic stem cell transplantation (HSCT). The majority of cases occurred after a cycle of chemotherapy rather than after stem cell transplant. PRES after chemotherapy significantly differs from that after HSCT for diagnosis, time of presentation, risk factors, management, and outcome. CONCLUSIONS This study demonstrates that PRES is a common neurological complication and occurring preferentially in course of induction treatment of some hematologic malignancies, as ALL and after HSCT. It also highlights great clinical differences in the management and outcome in patients with PRES occurring after chemotherapy or after HSCT.
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Affiliation(s)
- Daniele Zama
- Department of Pediatrics, Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", Sant' Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pietro Gasperini
- Department of Pediatrics, Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", Sant' Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Massimo Berger
- Pediatric Onco-Hematology and Stem Cell Transplant Division, City of Health and Science, Regina Margherita Children's Hospital, Turin, Italy
| | | | - Maria D De Pasquale
- Department of Pediatric Hematology/Oncology and Stem Cell Transplantation, Bambino Gesù Children's Hospital, Rome, Italy
| | - Simone Cesaro
- Department of Paediatrics, Paediatric Haematology Oncology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Maria E Guerzoni
- Department of Medical and Surgical Sciences for Mothers, Children and Adults, Onco-hematology Pediatric Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Mastrodicasa
- Pediatric Onco-Hematology and Stem Cell Transplant Unit, S.Maria della Misericordia Hospital, Perugia, Italy
| | | | - Ottavio Ziino
- Pediatric Hematology-Oncology, ARNAS Civico, Palermo, Italy
| | - Valentina Kiren
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | | | - Rosa M Mura
- Paediatric Haematology-Oncology, Ospedale Pediatrico Microcitemico, Cagliari, Italy
| | - Fraia Melchionda
- Department of Pediatrics, Pediatric Oncology and Haematology Unit "Lalla Seràgnoli", Sant' Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giulio A Zanazzo
- Pediatric Hematology-Oncology, Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
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25
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Lincoln CM, Fata P, Sotardi S, Pohlen M, Uribe T, Bello JA. Imaging spectrum of immunomodulating, chemotherapeutic and radiation therapy-related intracranial effects. Br J Radiol 2017; 91:20170553. [PMID: 29039692 DOI: 10.1259/bjr.20170553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE A wide range of treatment-related side effects result in specific neurologic symptoms and signs and neuroimaging features. Even to the most seasoned neuroradiologist, elucidating therapy-related side effects from other common mimics can be challenging. We provide a pictorial survey of some common and uncommon medication-induced and therapy-related neuroimaging manifestations, discuss pathophysiology and common pitfalls in imaging and diagnosis. METHODS A case-based review is utilized to depict scenarios on a routine basis in a general radiology or neuroradiology practice such as medication-induced posterior reversible encephalopathy syndrome to the more challenging cases of pseudoprogression and pseudoregression in temozolmide and bevacizumab therapy in gliobastoma treatment protocols. CONCLUSION Knowledge of the treatment-induced imaging abnormalities is essential in the accurate interpretation and diagnosis from the most routine to most challenging of clinical situations. We provide a pictorial review for the radiologist to employ in order to be an invaluable provider to our clinical colleagues and patients.
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Affiliation(s)
- Christie M Lincoln
- 1 Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Peter Fata
- 2 Department of Radiology, Houston Methodist , Houston, TX , USA
| | - Susan Sotardi
- 3 Department of Neuroradiology, Massachusetts General Hospital , Boston, MA , USA
| | - Michael Pohlen
- 1 Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Tomas Uribe
- 1 Department of Radiology, Baylor College of Medicine , Houston, TX , USA
| | - Jacqueline A Bello
- 4 Albert Einstein College of Medicine, Montefiore Medical Center , Bronx, NY , USA
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26
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Miaris N, Sgouros J, Gerolympou M, Spyropoulos B, Drakopoulos D, Gkoura S, Res H, Samantas E. Posterior Reversible Encephalopathy Syndrome During Treatment with Aflibercept, 5-Fluorouracil, Leucovorin, and Irinotecan for Metastatic Colorectal Cancer. J Gastrointest Cancer 2017; 50:123-126. [PMID: 28660523 DOI: 10.1007/s12029-017-9986-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Nikolaos Miaris
- Third Department of Medical Oncology, 'Agioi Anargyroi' General Oncology Hospital of Kifisia, Noufaron and Timiou Stavrou 14, N. Kifisia, 14564, Athens, Greece.
| | - Joseph Sgouros
- Third Department of Medical Oncology, 'Agioi Anargyroi' General Oncology Hospital of Kifisia, Noufaron and Timiou Stavrou 14, N. Kifisia, 14564, Athens, Greece
| | - Margarita Gerolympou
- Third Department of Medical Oncology, 'Agioi Anargyroi' General Oncology Hospital of Kifisia, Noufaron and Timiou Stavrou 14, N. Kifisia, 14564, Athens, Greece
| | - Basilios Spyropoulos
- First Department of Internal Medicine, 401 General Military Hospital of Athens, Athens, Greece
| | | | - Stefania Gkoura
- Third Department of Medical Oncology, 'Agioi Anargyroi' General Oncology Hospital of Kifisia, Noufaron and Timiou Stavrou 14, N. Kifisia, 14564, Athens, Greece
| | - Helen Res
- Third Department of Medical Oncology, 'Agioi Anargyroi' General Oncology Hospital of Kifisia, Noufaron and Timiou Stavrou 14, N. Kifisia, 14564, Athens, Greece
| | - Epaminondas Samantas
- Third Department of Medical Oncology, 'Agioi Anargyroi' General Oncology Hospital of Kifisia, Noufaron and Timiou Stavrou 14, N. Kifisia, 14564, Athens, Greece
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27
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Blaye C, Buy X, Gross-Goupil M, Vincent D, Jamet C, Sargos P, Culine S, Roubaud G. Posterior reversible encephalopathy syndrome with colitis in a patient treated with panitumumab. Ther Adv Drug Saf 2017; 8:133-136. [PMID: 28439399 DOI: 10.1177/2042098616682720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Céline Blaye
- Department of Medical Oncology, Institut Bergonié, Bordeaux, France
| | - Xavier Buy
- Department of Radiology, Institut Bergonié, Bordeaux, France
| | | | - Didier Vincent
- Department of Neurology, Groupe Hospitalier La Rochelle, La Rochelle, France
| | - Claire Jamet
- Department of Medical Oncology, Groupe Hospitalier La Rochelle, La Rochelle, France
| | - Paul Sargos
- Department of Radiation Oncology, Institut Bergonié, Bordeaux, France
| | - Stéphane Culine
- Department of Medical Oncology, Centre Hospitalier Universitaire Saint Louis, Paris, France
| | - Guilhem Roubaud
- Department of Medical Oncology, Institut Bergonié, 229 Cours de l'Argonne, Bordeaux, 33000
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28
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Hadad LK, Billingsley CC. Posterior reversible encephalopathy syndrome (PRES) associated with ovarian cancer and voltage-gated potassium channel antibodies: A case report. Gynecol Oncol Rep 2017; 20:67-69. [PMID: 28349115 PMCID: PMC5357691 DOI: 10.1016/j.gore.2017.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 02/25/2017] [Accepted: 02/27/2017] [Indexed: 01/30/2023] Open
Abstract
We report a case of PRES in conjunction with high grade serous ovarian carcinoma There is a documented association between chemotherapy agents and PRES Paraneoplastic panel was positive for voltage-gated potassium channel antibodies Paraneoplastic workup may be justified in cases with high suspicion of PRES
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Affiliation(s)
- Laura K Hadad
- Department of Obstetrics and Gynecology, Division of Gynecology Oncology, University of Cincinnati, 231 Albert Sabin Way, Academic Health Center, PO Box 670526, Cincinnati, OH, 45267-0526, United States
| | - Caroline C Billingsley
- Department of Obstetrics and Gynecology, Division of Gynecology Oncology, University of Cincinnati, 231 Albert Sabin Way, Academic Health Center, PO Box 670526, Cincinnati, OH, 45267-0526, United States
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29
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Complications neurologiques centrales des traitements anticancéreux, ce que le réanimateur doit savoir. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-016-1252-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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30
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Posterior Reversible Encephalopathy Syndrome Associated With Dose-adjusted EPOCH (Etoposide, Prednisone, Vincristine, Cyclophosphamide, Doxorubicin) Chemotherapy. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:225-230. [PMID: 28169156 DOI: 10.1016/j.clml.2016.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 11/22/2016] [Accepted: 12/06/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The purpose of our study was to identify the key risk factors for the development of posterior reversible encephalopathy syndrome (PRES) after administration of the combination chemotherapy regimen, DA-EPOCH (dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin). MATERIALS AND METHODS We performed a retrospective medical record review of patients receiving DA-EPOCH with or without rituximab (DA-EPOCH ± R) at our institution from July 2012 to September 2014. The patients were screened for evidence of severe neurotoxicity through identification of requests for neurology consultations or neuroimaging studies. Patients with evidence of central nervous system (CNS) neurotoxicity were reviewed in detail to identify documented cases of PRES. The key risk factors assessed included rituximab administration sequence, and the presence of CNS insults, fluid status or electrolyte abnormalities, organ dysfunction, and hypertension. RESULTS A total of 44 patients received DA-EPOCH ± R at our institution from July 2012 to September 2014. Of these 44 patients, 3 (7%) were diagnosed with PRES. The patients who developed PRES were more likely to have a pre-existing CNS insult, fluid status or electrolytes abnormalities, and hypertension. CONCLUSION To the best of our knowledge, the present study is the first description of PRES associated with DA-EPOCH. The key risk factors for the development of PRES identified in our study included hypertension, fluid imbalance, electrolyte abnormalities, baseline organ dysfunction, a high tumor burden, and the presence of pre-existing CNS insults during chemotherapy, such as CNS infection. Patients with these risk factors appear to have a greater risk of developing PRES and should be monitored closely during treatment.
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31
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Pikija S, Pilz G, Gschwandtner G, Rösler C, Schlick K, Greil R, Sellner J. Panitumumab-Associated Encephalopathy after Accidental Intra-arterial Application through Dislocated Central Venous Access Device. Front Neurol 2016; 7:196. [PMID: 27872609 PMCID: PMC5098172 DOI: 10.3389/fneur.2016.00196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/24/2016] [Indexed: 11/13/2022] Open
Abstract
Acute central nervous system (CNS) toxicity and immune-related side effects are increasingly recognized with the use of monoclonal antibodies for cancer therapy. Here, we report a patient who developed of acute-onset encephalopathy and coma, which began shortly after administration of panitumumab for the treatment of metastatic colorectal cancer. Echocardiography revealed that the drug had been infused into the left cardiac ventricle via a dislocated central venous line. Diffusion-weighted magnetic resonance imaging disclosed multiple cortical hyperintensities, which were preferentially located in the frontal lobes. While the neurological condition improved within a few days, the patient died 4 weeks later. It seems likely that the administration of the antibody via the intra-arterial route contributed to the development of this condition. Toxic encephalopathy may be a hitherto unrecognized complication of panitumumab treatment and should be taken into consideration in patients developing CNS symptoms undergoing this therapy.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Georg Pilz
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Gerald Gschwandtner
- Department of Geriatric Medicine, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Cornelia Rösler
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Konstantin Schlick
- Laboratory of Immunological Molecular Cancer Research, Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Diseases, Rheumatology, Oncologic Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Richard Greil
- Laboratory of Immunological Molecular Cancer Research, Department of Internal Medicine III with Hematology, Medical Oncology, Hemostaseology, Infectious Diseases, Rheumatology, Oncologic Center, Paracelsus Medical University Salzburg , Salzburg , Austria
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University Salzburg, Salzburg, Austria; Department of Neurology, Klinikum rechts der Isar, Technische Universität München, München, Germany
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