Posterior reversible encephalopathy syndrome (PRES) after treatment with oxaliplatin and 5-fluorouracil

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.

The first two cases of posterior reversible encephalopathy syndrome (PRES) secondary to conventional transcatheter arterial chemoembolization of hepatocellular carcinoma

Background

Posterior reversible encephalopathy syndrome (PRES) is a very rare complication secondary to transcatheter arterial chemoembolization (TACE). Only two patients with liver metastasis have been reported. We report for the first time two cases of hepatocellular carcinoma (HCC) patients occurred PRES secondary toTACE.

Case presentation

The two patients with HCC developed headache, epilepsy, expressive aphasia, visual impairment and loss of consciousness, 11 and 3 h after conventional TACE (c-TACE) surgery. One patient experienced raised blood pressure during and after TACE, accompanied by a significant elevated creatinine. The magnetic resonance imaging (MRI) of the two patients showed multiple abnormal signals in the brain, mainly located in the white matter region. Combined with the clinical symptoms and MRI findings, PRES was diagnosed. Their symptoms and MRI changes improved significantly in the next two weeks.

Conclusion

The PRES in this report is chemoembolization-associated syndrome, which might be related to the use of chemotherapy agents during TACE. And if neurological symptoms occur after TACE, patients should be closely monitored to exclude PRES.

Posterior Reversible Encephalopathy Syndrome Associated with Oxaliplatin Use for Pancreatic Adenocarcinoma

The posterior reversible encephalopathy syndrome (PRES) was first described by Hinchey's group in 1996 as a reversible vasogenic brain edema on magnetic resonance imaging (MRI). Hypertension represents the most frequent manifestation associated with PRES. In the present report, we present a patient diagnosed with locally advanced pancreatic adenocarcinoma who received 3 cycles of a 5-fluoruracil plus oxaliplatin-based chemotherapy regimen and developed PRES after the third cycle. Several days after receiving the second cycle of FOLFOX chemotherapy, the patient started having episodes of hypertensive crisis (systolic pressure = 180, diastolic pressure = 100), that was controlled with amlodipine, irbesartan, and hydrochlorothiazide. After the administration of the third cycle, this time with the FOLFIRINOX regimen, he appeared lethargic and disoriented in place and time. MRI revealed bilateral areas of signal hyperintensity in the thalamus, hypothalamus, fibers of reticular formation, anterior section of cerebral vermis and a mild edema of left parahippocampal gyrus, with no signs of brain metastases. Ultimately, the patient was diagnosed with PRES syndrome, and he was treated with glucose, 5% saline, thiamine supplementation, levetiracetam (Keppra®), and i.v. dexamethasone. Three weeks later, he gradually became conscious, with cognitive function recovery, and capable of executing movements.

Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients

The posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.

Oxaliplatin-induced posterior reversible encephalopathy syndrome (PRES)

Posterior reversible encephalopathy syndrome (PRES), first introduced in 1996, is a neurotoxic state characterised by seizures, headache, vision change, paresis, nausea and altered mental status. Risk factors include hypertension, eclampsia/pre-eclampsia, infection/sepsis and cancer chemotherapy. Although exposure to toxic agents is a common occurrence in patients who develop PRES, oxaliplatin has rarely been associated with it, with only 10 cases reported worldwide. We present the case of an oxaliplatin-induced PRES in a 23-year-old male patient who was started on oxaliplatin/capecitabine as adjuvant chemotherapy for anal canal adenocarcinoma. The patient developed symptoms of headache, slurred speech and left-sided facial weakness on the ninth day after the first dose of oxaliplatin that lasted for 6-8 hours. The patient experienced another episode next day with similar symptoms that lasted for 8 hours. Oxaliplatin was withheld and the patient was discharged on capecitabine only. The patient had no new episodes since discharge on follow-up.

Chemotherapy-associated Posterior Reversible Encephalopathy Syndrome: A Case Report and Review of the Literature

INTRODUCTION

There are increasing reports of posterior reversible encephalopathy syndrome (PRES) associated with the use of chemotherapeutic agents. Recognition of PRES is crucial given its reversibility with appropriate supportive management. We report a patient presenting with PRES after treatment with Rituximab, Cyclophosphamide, Hydroxydaunorubicin/Adriamycin, Oncovin/Vincristine, Prednisone (R-CHOP) and intrathecal methotrexate. We also perform a systematic review of the literature on chemotherapy-associated PRES.

CASE REPORT

A 72-year-old man with recently diagnosed diffuse large B-cell lymphoma became unresponsive 4 days after initiation of R-CHOP and intrathecal methotrexate. Brain magnetic resonance imaging showed interval development of occipital and temporal fluid attenuation inversion recovery hyperintensities consistent with PRES. The patient's blood pressure was aggressively controlled and he received 5 days of high-dose methylprednisone. He subsequently regained consciousness and his mental status gradually improved. Repeat magnetic resonance imaging showed interval resolution of the bilateral fluid attenuation inversion recovery hyperintensities.

REVIEW SUMMARY

We performed a systematic review of the literature and included a total of 70 unique cases involving chemotherapy-associated PRES. Platinum-containing drugs, Cyclophosphamide, Hydroxydaunorubicin/Adriamycin, Oncovin/Vincristine, Prednisone/R-CHOP regimens, and gemcitabine were the agents most commonly used in patients who developed suspected chemo-associated PRES. Median onset of symptoms occurred 8 days after chemotherapy. Hypertension was the most commonly reported risk factor associated with the development of chemotherapy-associated PRES. In most cases, PRES improved with supportive management alone within 2 weeks.

CONCLUSIONS

Chemotherapy-associated PRES is an increasingly encountered syndrome. Both neurologists and non-neurologists should be familiar with the most commonly implicated agents, symptoms, risk factors, and clinical course of chemotherapy-associated PRES, given its favorable prognosis with appropriate management.

Acute hyperammonemic encephalopathy after 5-fluorouracil based chemotherapy

5-Fluorouracil (5-FU) based chemotherapy has been commonly used to treat metastatic or advanced colon cancer as an adjuvant chemotherapy. Although the side effects of 5-FU such as gastrointestinal problems and neutropenia and thrombocytopenia are common, not many cases of 5-FU related encephalopathy are reported. Hyperammonemic encephalopathy is a rare central nervous system toxicity following 5-FU chemotherapy manifesting as altered mental status with elevated ammonia levels with no radiologic abnormality. We report one case of 5-FU induced hyperammonemic encephalopathy occurring after Folfox4 (oxaliplatin, folinic acid and 5-fluorouracil) chemotherapy in a colon cancer patient who presented with confused mental status soon after the chemotherapy and review the 5-FU related encephalopathy.

Correlation analysis of STAT3 and VEGF expression and eosinophil infiltration in nasal polyps

The expression and distribution of signal transducer and activator of transcription 3 (STAT3), phosphorylated STAT3 (p-STAT3), and vascular endothelial growth factor (VEGF), as well as eosinophil infiltration in nasal polyps was detected to examine their roles and correlations in the nasal polyp pathogenesis. Using the streptavidin-biotin-peroxidase (SP) method, immunohistochemistry was performed on conventional paraffin sections of 30 surgery-resected polypous specimens and 10 inferior turbinate tissues that were resected during nasal septum deflection correction to detect the expression of STAT3, p-STAT3, and VEGF, as well as eosinophil infiltration. The rates of STAT3-, p-STAT3-, and VEGF-positive expression in the mucosal epithelium and glands of nasal polyps were 66.67, 56.67, and 76.67 %, respectively, values that were significantly higher than those in the inferior turbinate group. The number of eosinophils in the nasal polyps was significantly higher than in the inferior turbinate group. Expression of p-STAT3 and VEGF in nasal polyps and eosinophil infiltration was increased significantly and positively correlated, indicating that VEGF and eosinophil infiltration might be regulated by p-STAT3. Therefore, the expression of STAT3, p-STAT3, and VEGF, and eosinophil infiltration might be important factors in nasal polyp pathogenesis.

Posterior reversible encephalopathy syndrome resulting from repeat bortezomib usage

Bortezomib is a chemotherapeutic agent that acts via proteasome inhibition resulting in cellular apoptosis and inhibition of angiogenesis. Although widely accepted as treatment of multiple myeloma and non-Hodgkin's lymphoma, it has also been shown to be efficacious in a variety of solid tumours such as pancreatic and colonic. Posterior reversible encephalopathy syndrome (PRES) is a neuroradiological syndrome characterised by vasogenic oedema involving the postero-occipital cortical and subcortical white matter resulting in visual disturbances, seizures and altered mental status. Although in most cases PRES is reversible with removal of the provoking condition or drug, if not appropriately recognised and treated it may lead to permanent and life-threatening sequelae such as intracerebral haemorrhage and ischaemic infarction. We report a case of PRES associated with bortezomib therapy and contrast it with four other previously reported cases. Recognition of this potentially severe neurological complication is important with the increasingly widespread use of bortezomib.