Chemotherapy induced stroke mimic: 5-Fluorouracil encephalopathy fulfilling criteria for tissue plasminogen activator therapy

Transient Coma and Signs of Encephalopathy Related to 5-Fluorouracil and Carboplatin: A Case Report

Chemotherapy-related encephalopathy is a rare but severe side effect of cancer therapy. Few reports exist on the course of encephalopathy due to 5-fluorouracil (5FU)/carboplatin treatment. Here, we report on a patient in his 70s, who received first-line palliative treatment with carboplatin followed by continuous infusion of 5FU against a metastasized cancer of the base of the tongue. During the first 5FU infusion, the patient developed a coma with sudden onset. In contrast to earlier reports of 5FU-induced encephalopathy, serum ammonium levels were near-normal, despite a slightly increased bilirubin. The electroencephalogram showed signs of general encephalopathy, for which no other probable cause than chemotherapy could be identified. Based on historical reports, the patient's encephalopathy was likely due to 5FU treatment rather than carboplatin. While initially in a coma with a Glasgow Coma Scale score of three, the patient regained consciousness within 3 days of supportive therapy. This case highlights the potentially benign clinical course of 5FU-induced encephalopathy, characterized by fulminant clinical deterioration and quick recovery. Such a rapid deterioration in a palliative setting can pose a clinical dilemma, where invasive treatments such as intubation must be weighed against a limited prognosis, for which this case may provide guidance.

Chemotherapy-Induced Neuropathy and Diabetes: A Scoping Review

Although cancer and diabetes are common diseases, the relationship between diabetes, neuropathy and the risk of developing peripheral sensory neuropathy while or after receiving chemotherapy is uncertain. In this review, we highlight the effects of chemotherapy on the onset or progression of neuropathy in diabetic patients. We searched the literature in Medline and Scopus, covering all entries until 31 January 2021. The inclusion and exclusion criteria were: (1) original article (2) full text published in English or Spanish; (3) neuropathy was specifically assessed (4) the authors separately analyzed the outcomes in diabetic patients. A total of 259 papers were retrieved. Finally, eight articles fulfilled the criteria, and four more articles were retrieved from the references of the selected articles. The analysis of the studies covered the information about neuropathy recorded in 768 cancer patients with diabetes and 5247 control cases (non-diabetic patients). The drugs investigated are chemotherapy drugs with high potential to induce neuropathy, such as platinum derivatives and taxanes, which are currently the mainstay of treatment of various cancers. The predisposing effect of co-morbid diabetes on chemotherapy-induced peripheral neuropathy depends on the type of symptoms and drug used, but manifest at any drug regimen dosage, although greater neuropathic signs are also observed at higher dosages in diabetic patients. The deleterious effects of chemotherapy on diabetic patients seem to last longer, since peripheral neuropathy persisted in a higher proportion of diabetic patients than non-diabetic patients for up to two years after treatment. Future studies investigating the risk of developing peripheral neuropathy in cancer patients with comorbid diabetes need to consider the duration of diabetes, cancer-induced neuropathic effects per se (prior chemotherapy administration), and the effects of previous cancer management strategies such as radiotherapy and surgery.

5-Fluorouracil associated neurovascular toxicities

Fluorouracil (5-FU) is a commonly used chemotherapeutic agent in many cancers. The widely reported adverse effects are infusion reactions, rash, fever, nausea, vomiting, peripheral neuropathy, and hepatic injury. However, there are limited data about its neurological side effects. Herein, we are reporting 3 cases of 5-FU induced neurovascular toxicities. Cerebral vasospasm with associated transient ischemia is a rare but significant adverse effect of the 5-FU. Stroke-like presentation makes timely recognition extraordinarily important. Differentiating stroke mimics is crucial as recombinant tissue plasminogen activator therapy should be given within a 4.5 hours window after an ischemic stroke. We suggest that 5-FU induced cerebral vasospasm can present with acute stroke-like symptoms. Physicians should be aware of stroke mimics as a differential diagnosis to spare their patients from unnecessary invasive and high-risk treatments.

Case report on 5-fluorouracil induced cerebrovascular accident

Introduction

5-Fluorouracil is an antineoplastic agent generally used to treat various types of solid tumors. The common adverse drug reaction associated with 5-fluorouracil are myelosuppression, mucositis, diarrhea, and hand-foot syndrome. Neurological side effects such as headache, dizziness, convulsion, encephalopathy, and acute cerebellar syndrome are rare in nature.

Case presentation

We report a case of 5-fluorouracil induced cerebrovascular accident (CVA) in a patient with no risk factors for CVA before chemotherapy. A 37 years old female patient diagnosed with carcinoma rectum underwent six cycles of chemotherapy with 5- fluorouracil- calcium leucovorin- irinotecan (FOLFIRI regimen). After completing the last cycle, she developed headache, vomiting, and facial deviation along with high blood pressure (260/160 mmHg). MRI brain was done, and it revealed acute non-hemorrhagic lacunar infarct in the left half of pons. 5-fluorouracil induced CVA was suspected and was managed with dual antiplatelet, statin, and antihypertensives.

Conclusion

The clinicians and clinical pharmacists must be aware about the potential of 5-FU to induce rare side effects such as CVA even in low risk patients in order to avoid permanent harm to the patient

Peripheral Artery Disease and Stroke

Peripheral artery disease (PAD) and stroke can occur as vascular complication of anticancer treatment. Although the mechanisms, monitoring, and management of cardiotoxicities have received broad attention, vascular toxicities remain often underrecognized. In addition, the development of new chemotherapeutic drugs bears the risk of vasotoxicities that are yet to be identified and may not be realized with short-term follow-up periods. The propensity to develop PAD and/or stroke reflects the complex interplay between patient's baseline risk and preexisting vascular disease, particularly hypertension and diabetes, while evidence for genetic predisposition is increasing. Chemotherapeutic agents with a prominent vascular side effect profile have been identified. Interruption of vascular endothelial growth factor (VEGF) inhibitors (VEGFIs) signaling (i.e., bevacizumab) is associated with vascular toxicity and clinical sequelae such as hypertension, stroke, and thromboembolism beyond acute coronary syndromes. Cisplatin and 5-fluorouracil are the main drugs involved in the stroke risk. In addition, circulating concentrations of VEGF are reduced by cyclophosphamide administered at continuous low doses, which might underpin some of the observed vascular toxicity, such as stroke, as seen in patients treated with VEGF inhibitors. The risk of stroke is also increased after treatment with anthracyclines that can induce endothelial dysfunction and increase arterial stiffness. Proteasome inhibitors ( bortezomib and carfilzomib) and immunomodulatory agents (thalidomide, lenalidomide, and pomalidomide), approved for use in multiple myeloma, carry a black box warning for an increased risk of stroke. Finally, head-and-neck radiotherapy is associated with a doubled risk of cerebrovascular ischemic event, especially if exposure occurs in childhood. The mechanisms involved in radiation vasculopathy are represented by endothelial dysfunction, medial necrosis, fibrosis, and accelerated atherosclerosis. However, BCR-ABL tyrosine kinase inhibitor (TKI), used for the treatment of chronic myeloid leukemia (CML), is the main antineoplastic drugs involved in the development of PAD. In particular, second- and third-generation TKIs, such as nilotinib and ponatinib, while emerging as a potent arm in contrasting CML, are associated with a higher risk of PAD development rather than traditional imatinib. Factors favoring vascular complication are the presence of traditional cardiovascular risk factors (CVRF) and predisposing genetic factors, high doses of BCR-ABL TKIs, longer time of drug exposure, and sequential use of potent TKIs. Therefore, accurate cardiovascular risk stratification is strongly recommended in patient candidate to anticancer treatment associated with higher risk of vascular complication, in order to reduce the incidence of PAD and stroke through CVRF correction and selection of appropriate tailored patient strategy of treatment. Then, a clinical follow-up, eventually associated with instrumental evaluation through vascular ultrasound, should be performed.

Common Vascular Toxicities of Cancer Therapies

The introduction of targeted agents into modern cancer therapy pursued the goal of molecularly more specific, and thereby more effective and safer, therapies. Paradoxically, however, several toxicities were brought to greater attention, among these not only cardiac but also vascular toxicities. The latter reach far beyond venous thromboembolism and include a broad spectrum of presentations based on the vascular territories and pathomechanisms involved, including abnormal vascular reactivity, acute thrombosis, or accelerated atherosclerosis. This article provides an overview of the most common presentations and their management strategies.

Acute reversible left ventricular systolic dysfunction associated with 5-fluorouracil therapy: a rare and increasingly recognised cardiotoxicity of a commonly used drug

5-Fluorouracil (5-FU) is the third most common chemotherapeutic agent for treating solid cancers and the second most common to cause cardiotoxicity. We present a rare case of acute reversible severe left ventricular systolic dysfunction associated with 5-FU. A 54-year-old woman with a history of stage IV gastric cancer presented with features of transient ischaemic attack after receiving the first dose of FLOT (5-FU, leucovorin, oxaliplatin and docetaxel). During the diagnostic workup, it was found that her ejection fraction was severely reduced to 15% with features of global hypokinesis, which later improved back to 65% within 13 days. These cases challenge our current understanding of the underlying mechanisms of this cardiotoxicity. Additionally, even though the patient did not experience any cardiac symptoms, it is important to monitor these patients closely as they are at high risk for fatal complications like arrhythmia and thrombus formation.