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Caufield JH, Hegde H, Emonet V, Harris NL, Joachimiak MP, Matentzoglu N, Kim H, Moxon S, Reese JT, Haendel MA, Robinson PN, Mungall CJ. Structured Prompt Interrogation and Recursive Extraction of Semantics (SPIRES): a method for populating knowledge bases using zero-shot learning. Bioinformatics 2024; 40:btae104. [PMID: 38383067 PMCID: PMC10924283 DOI: 10.1093/bioinformatics/btae104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 12/16/2023] [Accepted: 02/20/2024] [Indexed: 02/23/2024] Open
Abstract
MOTIVATION Creating knowledge bases and ontologies is a time consuming task that relies on manual curation. AI/NLP approaches can assist expert curators in populating these knowledge bases, but current approaches rely on extensive training data, and are not able to populate arbitrarily complex nested knowledge schemas. RESULTS Here we present Structured Prompt Interrogation and Recursive Extraction of Semantics (SPIRES), a Knowledge Extraction approach that relies on the ability of Large Language Models (LLMs) to perform zero-shot learning and general-purpose query answering from flexible prompts and return information conforming to a specified schema. Given a detailed, user-defined knowledge schema and an input text, SPIRES recursively performs prompt interrogation against an LLM to obtain a set of responses matching the provided schema. SPIRES uses existing ontologies and vocabularies to provide identifiers for matched elements. We present examples of applying SPIRES in different domains, including extraction of food recipes, multi-species cellular signaling pathways, disease treatments, multi-step drug mechanisms, and chemical to disease relationships. Current SPIRES accuracy is comparable to the mid-range of existing Relation Extraction methods, but greatly surpasses an LLM's native capability of grounding entities with unique identifiers. SPIRES has the advantage of easy customization, flexibility, and, crucially, the ability to perform new tasks in the absence of any new training data. This method supports a general strategy of leveraging the language interpreting capabilities of LLMs to assemble knowledge bases, assisting manual knowledge curation and acquisition while supporting validation with publicly-available databases and ontologies external to the LLM. AVAILABILITY AND IMPLEMENTATION SPIRES is available as part of the open source OntoGPT package: https://github.com/monarch-initiative/ontogpt.
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Affiliation(s)
- J Harry Caufield
- Biosystems Data Science, Division of Environmental Genomics and Systems Biology, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | - Harshad Hegde
- Biosystems Data Science, Division of Environmental Genomics and Systems Biology, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | - Vincent Emonet
- Institute of Data Science, Faculty of Science and Engineering, Maastricht University, 6200 MD Maastricht, The Netherlands
| | - Nomi L Harris
- Biosystems Data Science, Division of Environmental Genomics and Systems Biology, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | - Marcin P Joachimiak
- Biosystems Data Science, Division of Environmental Genomics and Systems Biology, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | | | - HyeongSik Kim
- Robert Bosch LLC, Sunnyvale, CA 94085, United States
| | - Sierra Moxon
- Biosystems Data Science, Division of Environmental Genomics and Systems Biology, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | - Justin T Reese
- Biosystems Data Science, Division of Environmental Genomics and Systems Biology, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
| | - Melissa A Haendel
- Department of Biomedical Informatics, University of Colorado, Anschutz Medical Campus, Aurora, CO 80217, United States
| | | | - Christopher J Mungall
- Biosystems Data Science, Division of Environmental Genomics and Systems Biology, Lawrence Berkeley National Laboratory, Berkeley, CA 94720, United States
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Oura M, Oguro F, Agatsuma N, Imamaki H, Nishikawa Y. Fluoropyrimidine usage in cases with hyperammonemia: real-world data study using the Japanese Adverse Drug Event Report (JADER) database. Cancer Chemother Pharmacol 2023; 92:7-14. [PMID: 37204512 DOI: 10.1007/s00280-023-04542-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/09/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE Fluoropyrimidines are anticancer drugs and can cause hyperammonemia both intravenously and orally. Renal dysfunction may interact with fluoropyrimidine to cause hyperammonemia. We performed quantitative analyses of hyperammonemia using a spontaneous report database to examine the frequency of intravenously and orally administered fluoropyrimidine, the reported frequency of fluoropyrimidine-related regimens, and fluoropyrimidine's interactions with chronic kidney disease (CKD). METHODS This study used data collected between April 2004 and March 2020 from the Japanese Adverse Drug Event Report database. The reporting odds ratio (ROR) of hyperammonemia was calculated for each fluoropyrimidine drug and was adjusted for age and sex. Heatmaps depicting the use of anticancer agents in patients with hyperammonemia were drawn. The interactions between CKD and the fluoropyrimidines were also calculated. These analyses were performed using multiple logistic regression. RESULTS Hyperammonemia was observed in 861 of the 641,736 adverse events reports. Fluorouracil was the most frequent drug associated with hyperammonemia (389 cases). The ROR of hyperammonemia was 32.5 (95% CI 28.3-37.2) for intravenously administered fluorouracil, 4.7 (95% CI 3.3-6.6) for orally administered capecitabine, 1.9 (95% CI 0.87-4.3) for tegafur/uracil, and 2.2 (95% CI 1.5-3.2) for orally administered tegafur/gimeracil/oteracil. Calcium levofolinate, oxaliplatin, bevacizumab, and irinotecan were the most frequently reported agents in cases of hyperammonemia with intravenously administered fluorouracil. The coefficient of the interaction term between CKD and fluoropyrimidines was 1.12 (95% CI 1.09-1.16). CONCLUSION Hyperammonemia cases were more likely to be reported with intravenous fluorouracil than orally administered fluoropyrimidines. Fluoropyrimidines might interact with CKD in hyperammonemia cases.
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Affiliation(s)
- Mitsuaki Oura
- Department of Internal Medicine, Takeda General Hospital, Fukushima, Japan
| | - Fumiya Oguro
- Department of Internal Medicine, Hirata Central Hospital, Fukushima, Japan
| | - Nobukazu Agatsuma
- Department of Gastroenterology and Hepatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hirotaka Imamaki
- Department of Nephrology, Hirakata Kohsai Hospital, Osaka, Japan
| | - Yoshitaka Nishikawa
- Department of Health Informatics, Kyoto University School of Public Health, Yoshidakonoecho, Sakyo-ku, Kyoto, 606-8501, Japan.
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Zupancic M, Farrajota Neves da Silva P, Kas Elyas K, Friesland S, Ellingsen Cederö T, Gerling M. Transient Coma and Signs of Encephalopathy Related to 5-Fluorouracil and Carboplatin: A Case Report. Case Rep Oncol 2023; 16:525-531. [PMID: 37485017 PMCID: PMC10359680 DOI: 10.1159/000531472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/26/2023] [Indexed: 07/25/2023] Open
Abstract
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.
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Affiliation(s)
- Mark Zupancic
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden
| | - Pedro Farrajota Neves da Silva
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden
- Clinical Pathology and Cancer Diagnostics, Karolinska University Hospital, Stockholm, Sweden
| | - Karam Kas Elyas
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Signe Friesland
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Solna, Sweden
| | - Thomasine Ellingsen Cederö
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Gerling
- Medical Unit Head, Neck, Lung, and Skin Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
- Department of Biosciences and Nutrition, Karolinska Institutet, Huddinge, Sweden
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Gupta P, Makkar TK, Goel L, Pahuja M. Role of inflammation and oxidative stress in chemotherapy-induced neurotoxicity. Immunol Res 2022; 70:725-741. [PMID: 35859244 DOI: 10.1007/s12026-022-09307-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022]
Abstract
Chemotherapeutic agents may adversely affect the nervous system, including the neural precursor cells as well as the white matter. Although the mechanisms are not completely understood, several hypotheses connecting inflammation and oxidative stress with neurotoxicity are now emerging. The proposed mechanisms differ depending on the class of drug. For example, toxicity due to cisplatin occurs due to activation of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), which alters hippocampal long-term potentiation. Free radical injury is also involved in the cisplatin-mediated neurotoxicity as dysregulation of nuclear factor erythroid 2-related factor 2 (Nrf2) has been seen which protects against the free radical injury by regulating glutathione S-transferases and hemeoxygenase-1 (HO-1). Thus, correcting the imbalance between NF-κB and Nrf2/HO-1 pathways may alleviate cisplatin-induced neurotoxicity. With newer agents like bortezomib, peripheral neuropathy occurs due to up-regulation of TNF-α and IL-6 in the sensory neurons. Superoxide dismutase dysregulation is also involved in bortezomib-induced neuropathy. This article reviews the available literature on inflammation and oxidative stress in neurotoxicity caused by various classes of chemotherapeutic agents. It covers the conventional medicines like platinum compounds, vinca alkaloids, and methotrexate, as well as the newer therapeutic agents like immunomodulators and immune checkpoint inhibitors. A better understanding of the pathophysiology will lead to further advancement in strategies for management of chemotherapy-induced neurotoxicity.
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Affiliation(s)
- Pooja Gupta
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India. .,Coordinator, AIIMS Adverse Drug Reaction Monitoring Centre, Pharmacovigilance Program of India, New Delhi, India.
| | - Tavneet Kaur Makkar
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Lavisha Goel
- Department of Pharmacology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Monika Pahuja
- Division of Basic Medical Sciences, Indian Council of Medical Research, New Delhi, India
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Ashish S, Raj MS, Monga D, Finley G. Rechallenging Fluoropyrimidine-Induced Cardiotoxicity and Neurotoxicity: A Report of Two Cases. Cureus 2022; 14:e26824. [PMID: 35971344 PMCID: PMC9372383 DOI: 10.7759/cureus.26824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2022] [Indexed: 11/22/2022] Open
Abstract
Fluoropyrimidines (FP’s) such as fluorouracil (5-FU) and capecitabine are antimetabolites widely used in many solid tumors. FPs side effects are caused mainly by a lack of dihydropyrimidine dehydrogenase (DPD) enzyme. It has been noticed that treatment with infusional regimens of 5-FU is associated with more adverse events (AE) compared to bolus forms. Here, we report two cases of unusual side effects seen with infusional 5-FU and capecitabine and how early intervention by withholding ongoing treatment can help in preventing progression and mortality.
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Eguchi H, Kakiuchi T, Nishi M, Kojima-Ishii K, Nishiyama K, Koga Y, Matsuo M. Case Report: Juvenile Myelomonocytic Leukemia Underlying Ornithine Transcarbamylase Deficiency Safely Treated Using Hematopoietic Stem Cell Transplantation. Front Pediatr 2022; 10:898531. [PMID: 35601422 PMCID: PMC9120833 DOI: 10.3389/fped.2022.898531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/14/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Juvenile myelomonocytic leukemia (JMML), which is predominantly found in infants, is a clonal abnormality of pluripotent hematopoietic stem cells and presents with the symptoms of both myeloproliferative tumors and myelodysplastic syndromes. Estimates have shown that ~20 cases of JMML occur annually in Japan. Ornithine transcarbamylase deficiency (OTCD), the most common among all urea cycle disorders (UCDs), occurs in 1 of 80,000 people in Japan. CASE PRESENTATION A 10-month-old infant who had fever, vomiting, and diarrhea for 2 days was referred to our hospital for the following abnormalities in blood tests: white blood cell count, 48,200/μL; hemoglobin, 9.0 g/dL; and platelet count, 135,000/μL. Bone marrow examination showed a nucleated cell count of 396,000/mm3 and blast cell count of 5.0%, as well as decreased mature granulocyte count and slightly myeloperoxidase stain-negative blasts but no monoclonal cell proliferation on May-Giemsa staining. Colony assay showed the proliferation of spontaneous colony and high sensitivity to granulocyte-macrophage colony-stimulating factor. Genetic analysis of peripheral blood mononuclear cells showed that the patient was positive for neuroblastoma RAS (NRAS) mutation. The patient was ultimately diagnosed with JMML. Approximately 170 days after his first hematopoietic stem cell transplantation (HSCT), the patient's JMML relapsed. Shortly after the recurrence, nausea, vomiting, hyperventilation, and decreased vitality were observed, followed by a decrease in the level of consciousness. The patient's ammonia level was 472 μmol/L. A test for seven different genetic mutations for the UCD showed the presence of c. 119G>A (amino acid change p. Arg40His). As such, late-onset OTCD was added to his diagnosis. Administration of sodium phenylacetate, l-arginine hydrochloride, and carnitine was continued following the diagnosis of OTCD, after which hyperammonemia was not observed. Regarding JMML relapse, HSCT was performed on day 405 after the first transplantation. CONCLUSION Hyperammonemia should be considered a differential diagnosis when unexplained and non-specific symptoms occur during the treatment of hematologic malignancies. Patients should be tested for UCD as a cause of hyperammonemia, and treatment for hyperammonemia should be continued until the cause is identified. The patient shows normal developmental progress, has an intact neurological status, and has not experienced another hyperammonemia attack. His JMML has remained in remission for over 3 years.
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Affiliation(s)
- Hiroi Eguchi
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Toshihiko Kakiuchi
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Masanori Nishi
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Kanako Kojima-Ishii
- Department of Pediatrics, Graduate School of Medicine Sciences, Kyushu University, Fukuoka, Japan
| | - Kei Nishiyama
- Department of Pediatrics, Graduate School of Medicine Sciences, Kyushu University, Fukuoka, Japan
| | - Yuhki Koga
- Department of Pediatrics, Graduate School of Medicine Sciences, Kyushu University, Fukuoka, Japan
| | - Muneaki Matsuo
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
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Okamoto K, Nozawa H, Hongo K, Iida Y, Kawai K, Sasaki K, Murono K, Kita Y, Ishihara Y, Takabayashi N, Kobayashi R, Hiramatsu T, Ishihara S. Risk factors of mFOLFOX6-induced hyperammonemia in patients with colorectal cancer: an observational study. Int J Clin Oncol 2021; 26:1477-1484. [PMID: 33991268 DOI: 10.1007/s10147-021-01932-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 05/01/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND FOLFOX therapy, a standard treatment for colorectal cancer (CRC), causes a rare, but serious adverse event, hyperammonemia. However, the risk factors of hyperammonemia remain unknown. METHODS We examined 74 patients who received mFOLFOX6 therapy with or without biologics for CRC between April 2013 and March 2018 in Yaizu City Hospital. Clinicopathological factors were retrospectively reviewed in association with hyperammonemia, and risk factors of hyperammonemia during mFOLFOX6 therapy were analyzed in 32 patients with the available data. RESULTS Seven patients developed hyperammonemia, with onset exclusively on day 2 or 3 in the first cycle of therapy. They were treated with branched chain amino acid administration and hydration; however, one patient with stage G4 chronic kidney disease (CKD) died. By multivariate analysis, estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 was independently associated with hyperammonemia during FOLFOX therapy (odds ratio: 9.0, p = 0.040). CONCLUSIONS Reduced eGFR is considered a risk factor of developing hyperammonemia during FOLFOX therapy. Serum ammonia levels should be monitored especially during the first cycle of FOLFOX therapy in patients with CKD stage G3 or higher.
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Affiliation(s)
- Kazuaki Okamoto
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan. .,Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan.
| | - Hiroaki Nozawa
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kumiko Hongo
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan.,Department of Surgery, Hiratsuka City Hospital, 1-19-1, Minamihara, Hiratsuka-shi, Kanagawa, 254-0065, Japan
| | - Yuuki Iida
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.,Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Kazushige Kawai
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Koji Murono
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yusuke Kita
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Yukio Ishihara
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Naoki Takabayashi
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Ryo Kobayashi
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Takeyuki Hiramatsu
- Department of Surgery, Yaizu City Hospital, 1000, Doubara, Yaizu-shi, Shizuoka, 425-8505, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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VanderVeen BN, Sougiannis AT, Velazquez KT, Carson JA, Fan D, Murphy EA. The Acute Effects of 5 Fluorouracil on Skeletal Muscle Resident and Infiltrating Immune Cells in Mice. Front Physiol 2020; 11:593468. [PMID: 33364975 PMCID: PMC7750461 DOI: 10.3389/fphys.2020.593468] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/13/2020] [Indexed: 12/14/2022] Open
Abstract
5 fluorouracil (5FU) has been a first-choice chemotherapy drug for several cancer types (e.g., colon, breast, head, and neck); however, its efficacy is diminished by patient acquired resistance and pervasive side effects. Leukopenia is a hallmark of 5FU; however, the impact of 5FU-induced leukopenia on healthy tissue is only becoming unearthed. Recently, skeletal muscle has been shown to be impacted by 5FU in clinical and preclinical settings and weakness and fatigue remain among the most consistent complaints in cancer patients undergoing chemotherapy. Monocytes, or more specifically macrophages, are the predominate immune cell in skeletal muscle which regulate turnover and homeostasis through removal of damaged or old materials as well as coordinate skeletal muscle repair and remodeling. Whether 5FU-induced leukopenia extends beyond circulation to impact resident and infiltrating skeletal muscle immune cells has not been examined. The purpose of the study was to examine the acute effects of 5FU on resident and infiltrating skeletal muscle monocytes and inflammatory mediators. Male C57BL/6 mice were given a physiologically translatable dose (35 mg/kg) of 5FU, or PBS, i.p. once daily for 5 days to recapitulate 1 dosing cycle. Our results demonstrate that 5FU reduced circulating leukocytes, erythrocytes, and thrombocytes while inducing significant body weight loss (>5%). Flow cytometry analysis of the skeletal muscle indicated a reduction in total CD45+ immune cells with a corresponding decrease in total CD45+CD11b+ monocytes. There was a strong relationship between circulating leukocytes and skeletal muscle CD45+ immune cells. Skeletal muscle Ly6cHigh activated monocytes and M1-like macrophages were reduced with 5FU treatment while total M2-like CD206+CD11c- macrophages were unchanged. Interestingly, 5FU reduced bone marrow CD45+ immune cells and CD45+CD11b+ monocytes. Our results demonstrate that 5FU induced body weight loss and decreased skeletal muscle CD45+ immune cells in association with a reduction in infiltrating Ly6cHigh monocytes. Interestingly, the loss of skeletal muscle immune cells occurred with bone marrow cell cycle arrest. Together our results highlight that skeletal muscle is sensitive to 5FU's off-target effects which disrupts both circulating and skeletal muscle immune cells.
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Affiliation(s)
- Brandon N. VanderVeen
- Department of Pathology, Microbiology, and Immunology, University of South Carolina School of Medicine, Columbia, SC, United States
- AcePre, LLC, Columbia, SC, United States
| | - Alexander T. Sougiannis
- Department of Pathology, Microbiology, and Immunology, University of South Carolina School of Medicine, Columbia, SC, United States
| | - Kandy T. Velazquez
- Department of Pathology, Microbiology, and Immunology, University of South Carolina School of Medicine, Columbia, SC, United States
| | - James A. Carson
- Department of Physical Therapy, College of Health Professionals, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Daping Fan
- AcePre, LLC, Columbia, SC, United States
- Department of Cell Biology and Anatomy, University of South Carolina School of Medicine, Columbia, SC, United States
| | - E. Angela Murphy
- Department of Pathology, Microbiology, and Immunology, University of South Carolina School of Medicine, Columbia, SC, United States
- AcePre, LLC, Columbia, SC, United States
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Hyperammonemic encephalopathy during XELOX regimen. Is it capecitabine or oxaliplatin responsible? Anticancer Drugs 2020; 31:1103-1105. [PMID: 32826413 DOI: 10.1097/cad.0000000000000987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hyperammonemic encephalopathy represents a rare adverse effect of several chemotherapeutic agents, occurring in about 0.7% of patients treated with fluoropyrimidines, and it is independent from dihydropyrimidine dehydrogenase deficiency. Instead, its physiopathology is linked to the inhibition of Krebs cycle by fluoroacetate, leading to decreased ATP production, and to the inhibition of the urea cycle. Oxaliplatin seems to induce hyperammonemic encephalopathy in a similar way, acting on mitochondria. Here, we report the intriguing case of acute hyperammonemic encephalopathy in a 65-year-old patient with preserved liver function, who was treated with oxaliplatin and capecitabine for a metastatic, G1, atypical lung carcinoid. We reviewed the literature and found very few reports of oxaliplatin or capecitabine-induced hyperammonemic encephalopathy. Out of five cases of capecitabine-related hyperammonemic encephalopathy analyzed (four plus our case), median time to hyperammonemic encephalopathy onset was 6 days, with median serum ammonia levels of 213 μmol/L. Oxaliplatin-related hyperammonemic encephalopathy analyzed cases were three (two plus ours), with a median time to hyperammonemic encephalopathy of 11 days and median serum ammonia levels of 167 μmol/L. Identified predisposing factors for chemotherapy-induced hyperammonemia, such as dehydration, liver and renal impairment, infections, and sarcopenia were absent in our case. We hypothesize that the combination of a platinum-derivative and a fluoropyrimidine multiplies the risk of hyperammonemic encephalopathy, even in the absence of predisposing factors nor impaired liver function. We therefore suggest to always consider the risk of hyperammonemia when starting fluoropyrimidines-based chemotherapy, especially combined with platinum-derivatives, and to timely investigate neurologic symptoms monitoring ammonia serum levels.
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Fukuda M, Nabeta M, Muta T, Cho T, Shimamatsu Y, Shimotsuura Y, Fukami K, Takasu O. Disturbance of consciousness due to hyperammonemia and lactic acidosis during mFOLFOX6 regimen: Case report. Medicine (Baltimore) 2020; 99:e21743. [PMID: 32872062 PMCID: PMC7437776 DOI: 10.1097/md.0000000000021743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION FOLFOX therapy is the main chemotherapy regimen for colorectal cancer. Peripheral neuropathy, hematotoxicity, and digestive symptoms are known to be the most frequent adverse events. Hyperammonemia and lactic acidosis rarely occur simultaneously during treatment with FOLFOX therapy; the number of case reports is limited worldwide. We report a case of disturbance of consciousness, considered to be caused by hyperammonemia and lactic acidosis that occurred during treatment with mFOLFOX6 therapy that was administered as postoperative adjuvant treatment for rectal cancer. PATIENT CONCERNS This case was of a 71-year-old man who had been receiving oral treatment for chronic kidney disease and diabetes mellitus. Laparoscopic low anterior resection and artificial anal construction surgery were performed for stage III rectal cancer. As adjuvant postoperative therapy, mFOLFOX6 therapy was started but was followed by a disturbance of consciousness. DIAGNOSES Results of the blood tests revealed notable hyperammonemia (ammonia level, 1,163 μg/dl) and lactic acidosis (pH 7.207; lactate, 17.56 mmol/L); however, imaging diagnosis did not reveal intracranial lesions that could cause disturbance of consciousness. INTERVENTIONS For hyperammonemia, branched-chain amino acid agents and Ringers solution supplementation were administered. For acidosis, 7% sodium hydrogen carbonate was administered as treatment. OUTCOMES The disturbance of consciousness improved within 12 hours of initiating the treatment, and the patient was discharged with no sequelae on 7th day after hospitalization. CONCLUSION In patients with chronic kidney disease, FOLFOX regimen may confer risks of hyperammonemia and lactic acidosis.
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Affiliation(s)
- Masafumi Fukuda
- Advanced Emergency and Critical Care Center, Kurume University Hospital
| | | | - Takanori Muta
- Department of Emergency and Acute Intensive Care Medicine
| | | | | | | | - Kei Fukami
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Osamu Takasu
- Department of Emergency and Acute Intensive Care Medicine
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Boilève A, Thomas L, Lillo-Le Louët A, Gaboriau L, Chouchana L, Ducreux M, Malka D, Boige V, Hollebecque A, Hillaire-Buys D, Jozwiak M. 5-Fluorouracil-induced hyperammonaemic encephalopathy: A French national survey. Eur J Cancer 2020; 129:32-40. [PMID: 32120273 DOI: 10.1016/j.ejca.2020.01.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/15/2020] [Accepted: 01/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND 5-Fluorouracil (5-FU)-induced hyperammonaemic encephalopathy is a rare but serious 5-FU adverse drug reaction (ADR). Given the growing number of cancers treated with 5-FU and the paucity of data regarding this ADR, we performed a retrospective national survey to better characterise 5-FU-induced hyperammonaemic encephalopathy. PATIENTS AND METHODS Since inception of the French pharmacovigilance database, we identified all patients who experienced 5-FU-induced hyperammonaemic encephalopathy. Variables regarding demographics, characteristics, management and outcome of patients were collected. RESULTS From 1986 to 2018, 30 patients were included. 5-FU-induced hyperammonaemic encephalopathy started 2 [1-4] days after 5-FU infusion onset. Most common neurological disorders were consciousness impairment, seizures and confusion. hyperammonaemia tended to be higher in patients with the lowest Glasgow score and admitted in intensive care unit (ICU) compared to non-ICU patients (250 [133-522] versus 139 [68-220] μmol/L respectively, p = NS). Dihydropyrimidine dehydrogenase deficiency was found in 27% of tested patients (n = 3/11). Encephalopathy-induced mortality was 17%, 57% of patients were admitted in ICU and 70% had a complete neurological recovery within 5 [2-10] days. A 5-FU rechallenge was considered in 14 (67%) patients with neurological recovery and a relapse was observed in 57% of them. No 5-FU-induced hyperammonaemic encephalopathy relapse was observed as long as 5-FU rechallenge was performed with decreased 5-FU dosage. CONCLUSION We report the largest cohort of 5-FU-induced hyperammonaemic encephalopathy cases so far. This ADR should be suspected and ammonaemia measured in all patients experiencing neurological disorders after 5-FU administration. In patients with complete neurological recovery, a 5-FU rechallenge could be cautiously considered.
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Affiliation(s)
- Alice Boilève
- Département de Médecine Oncologique, Institut Gustave Roussy, Villejuif, France.
| | - Laure Thomas
- Centre Régional de PharmacoVigilance, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Est, Hôpital Henri Mondor, Créteil, France
| | - Agnès Lillo-Le Louët
- Centre Régional de PharmacoVigilance, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Centre, Hôpital Européen Georges Pompidou, Paris, France
| | - Louise Gaboriau
- Centre Régional de PharmacoVigilance, Hôpital Universitaire de Lille, Lille, France
| | - Laurent Chouchana
- Centre Régional de PharmacoVigilance, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Paris, France
| | - Michel Ducreux
- Département de Médecine Oncologique, Institut Gustave Roussy, Villejuif, France; Université Paris-Saclay, Villejuif, France
| | - David Malka
- Département de Médecine Oncologique, Institut Gustave Roussy, Villejuif, France
| | - Valérie Boige
- Département de Médecine Oncologique, Institut Gustave Roussy, Villejuif, France
| | - Antoine Hollebecque
- Département de Médecine Oncologique, Institut Gustave Roussy, Villejuif, France
| | - Dominique Hillaire-Buys
- Centre Régional de PharmacoVigilance, Hôpital Universitaire de Montpellier, Montpellier France
| | - Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Paris-Centre, Hôpital Cochin, Paris, France
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Neves Briard J, Lezaic N, Keezer MR. Pearls & Oy-sters: Chemotherapy-associated hyperammonemic encephalopathy. Neurology 2020; 94:e874-e877. [DOI: 10.1212/wnl.0000000000009004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Fatal Idiopathic Hyperammonemia after Induction Chemotherapy for Acute Myeloid Leukemia. Case Rep Hematol 2020; 2020:3136074. [PMID: 32089907 PMCID: PMC7031708 DOI: 10.1155/2020/3136074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/13/2020] [Accepted: 01/21/2020] [Indexed: 12/03/2022] Open
Abstract
Idiopathic hyperammonemia is a rare but potentially fatal complication occurring in patients with acute leukemia or bone marrow transplantation. The role of some specific anticancer drugs may be discussed, but the etiology of hyperammonemia is often multifactorial. We report the case of a 40-year-old woman who developed fatal idiopathic hyperammonemia two weeks after induction chemotherapy with idarubicin-aracytine for acute myeloid leukemia. Despite intensive care management and extrarenal epuration, the patient was declared brain dead two days after hyperammonemia onset.
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A 5-Fluorouracil-Induced Hyperammonemic Encephalopathy Challenged with Capecitabine. Case Rep Oncol Med 2020; 2020:4216752. [PMID: 32082663 PMCID: PMC7013286 DOI: 10.1155/2020/4216752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/09/2020] [Indexed: 12/20/2022] Open
Abstract
Cancer patients presenting with altered mental status demand a broad differential with early recognition of the etiology. Failure to do so is associated with increased morbidity and mortality. Causes that must be considered include organ involvement of the cancer, electrolytes abnormalities, and even chemotherapeutic agents. A 32-year-old female patient had been recently started on FOLFOX for metastatic colon cancer. Her initial treatments were uneventful, but she later developed encephalopathy during day three of cycle five. During her evaluation, she was found to have hyperammonemia (84 mcmol/L), without hepatic failure, that resolved with stopping chemotherapy and supportive care. After a trial of home infusion fluorouracil, she developed hyperammonemic encephalopathy again. During both admissions, her symptoms resolved with IV hydration and cessation of chemotherapy. She was then successfully challenged with capecitabine (1000 mg/m2 daily), and additional hydration, and continued chemotherapy without recurrence of symptoms. Hyperammonemia is associated with fluorouracil though the mechanism is unclear. Suspected etiologies include either elevated levels of the drug due to slower metabolism or accumulation of certain metabolites. Additionally, risk factors such urease-producing bacterial infections, dehydration, and increased catabolism are thought to increase the risk for hyperammonemia. This case demonstrates the need for greater awareness of fluorouracil as a cause of hyperammonemic encephalopathy. Knowledge of this may allow for earlier recognition and reduced unnecessary testing.
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16
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Abstract
RATIONALE Adult hyperammonemia is most often the result of hepatic dysfunction. Hyperammonemia in the setting of normal hepatic function is a much less common phenomenon and has usually been associated with medications and certain disease states. Here, we present an unusual case of severe hyperammonemia caused physiologically by intense muscle activity in a patient lacking any evidence of liver disease. PATIENT CONCERNS A 36-year-old woman was brought to the emergency department for a suicide attempt after being found covered in Lysol and Clorox germicidal bleach. She was noted to be in a state of violent psychosis with extreme agitation and had to be sedated and intubated for airway protection. DIAGNOSIS AND INTERVENTIONS Initial labs revealed hyperammonemia, lactic acidosis, and anion gap metabolic acidosis. Aminotransferases, bilirubin, and creatine kinase (CK) were normal. Renal function, prothrombin time, activated partial thromboplastin time, and international normalized ratio were also unremarkable and remained so at 24 hours. Ethyl alcohol, acetaminophen, salicylate, and valproic acid were all undetectable in blood. She received 2 doses of lactulose overnight, with a subsequent bowel movement. Next day, her mentation, serum ammonia level, and lactic acid level were back to normal, and she was extubated. Aminotransferases and CK levels were elevated but improved with supportive care. A detailed history and relevant biochemical investigations were unremarkable for any other etiology of hyperammonemia including the common inborn errors of metabolism (IEM). The combination of clinical findings of extreme skeletal muscle activity along with hyperammonemia and lactic acidosis, and subsequently rhabdomyolysis in the setting of unremarkable history and otherwise normal hepatic function strongly suggest the myokinetic origin of hyperammonemia in the patient. OUTCOME The patient recovered well with supportive care and was discharged on day 5. LESSONS This unique case illustrates the important role of skeletal muscle in the human metabolism of ammonia. In our discussion, we also elucidate the underlying pathophysiology, with the objective of improving clinician understanding of various differential diagnoses.
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Affiliation(s)
| | - Haneesh Jasuja
- Materials and Nanotechnology Program, North Dakota State University, Fargo, ND
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17
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5-Fluorouracil rechallenge after 5-fluorouracil-induced hyperammonemic encephalopathy. Anticancer Drugs 2019; 30:313-317. [DOI: 10.1097/cad.0000000000000730] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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18
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Ly KNI, Arrillaga-Romany IC. Neurologic Complications of Systemic Anticancer Therapy. Neurol Clin 2018; 36:627-651. [DOI: 10.1016/j.ncl.2018.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Ihoriya H, Yamamoto H, Yamada T, Tsukahara K, Inoue K, Yumoto T, Naito H, Nakao A. Hyperammonemic encephalopathy in a patient receiving fluorouracil/oxaliplatin chemotherapy. Clin Case Rep 2018; 6:603-605. [PMID: 29636922 PMCID: PMC5889268 DOI: 10.1002/ccr3.1422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/28/2017] [Accepted: 01/20/2018] [Indexed: 11/30/2022] Open
Abstract
Hyperammonemia is a rare adverse effect of 5‐fluorouracil (5‐FU) therapy, but can be very serious, even fatal. Physicians must be aware that hyperammonemic encephalopathy sometimes develops as an adverse event after 5‐FU therapy.
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Affiliation(s)
- Hiromi Ihoriya
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Hirotsugu Yamamoto
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Taihei Yamada
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Kohei Tsukahara
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Kanae Inoue
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Tetsuya Yumoto
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Hiromichi Naito
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
| | - Atsunori Nakao
- Department of Emergency and Critical Care Medicine Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences 2-5-1 Shikata-cho, Kita-ku Okayama-shi Okayama 700-8558 Japan
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20
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Kongsuphon N, Soukavanitch M, Teeraaumpornpunt N, Konmun J, Ativitavas T, Ngamphaiboon N. Multi-Targeted Tyrosine Kinase Inhibitor-Induced Hyperammonemic Encephalopathy: a Report of Two Cases Using Pazopanib, Sunitinib, and Regorafenib. J Gastrointest Cancer 2018; 50:601-603. [PMID: 29411249 DOI: 10.1007/s12029-018-0067-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Noppadon Kongsuphon
- Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Maturos Soukavanitch
- Division of Medical Oncology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Noramon Teeraaumpornpunt
- Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jitprapa Konmun
- Department of Pharmacy, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Touch Ativitavas
- Division of Medical Oncology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nuttapong Ngamphaiboon
- Division of Medical Oncology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
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21
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Strickler N, Balabanov S, Casauro K, Schanz U, Manz MG, Gerber B. Acute central nervous system complications and ammonium levels in adult patients with acute lymphoblastic leukemia receiving l-asparaginase. Leuk Lymphoma 2017; 59:855-862. [PMID: 28728499 DOI: 10.1080/10428194.2017.1352090] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
We analyzed ammonium levels and acute central nervous complications in adult patients receiving chemotherapy for acute lymphoblastic leukemia with or without asparaginase (l-asp). Twenty patients with a median age of 40.3 years were included. Ammonium-levels were measured during 88 chemotherapy cycles, 60 cycles (68%) with l-asp, and 28 cycles (32%) without l-asp. Ammonium was elevated in 87% of all l-asp containing cycles, with median ammonium levels of 169 μmol/l (interquartile range (IQR) 91-269 μmol/l). These values were higher when compared to ammonium levels at baseline (31.5 μmol/l, IQR 24-40 μmol/l, p < .001), and when compared to levels in cycles without l-asp (30 μmol/l, IQR 19-41 μmol/l, p < .001). Acute hyperammonemic encephalopathy was diagnosed in one patient, and encephalopathy for other reasons, but with hyperammonemia as a possible contributing factor in four patients. In conclusion, ammonium levels are elevated in all adult patients receiving l-asparaginase, but only some patients will present symptoms of encephalopathy.
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Affiliation(s)
- Nicole Strickler
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland
| | - Stefan Balabanov
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland
| | - Katharina Casauro
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland.,b Division of Hematology , Spital Maennedorf , Männedorf , Switzerland
| | - Urs Schanz
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland
| | - Markus G Manz
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland
| | - Bernhard Gerber
- a Department of Hematology and Oncology, Division of Hematology , University and University Hospital Zurich , Zurich , Switzerland.,c Division of Hematology , Oncology Institute of Southern Switzerland , Bellinzona , Switzerland
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22
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Mitani S, Kadowaki S, Komori A, Sugiyama K, Narita Y, Taniguchi H, Ura T, Ando M, Sato Y, Yamaura H, Inaba Y, Ishihara M, Tanaka T, Tajika M, Muro K. Acute hyperammonemic encephalopathy after fluoropyrimidine-based chemotherapy: A case series and review of the literature. Medicine (Baltimore) 2017; 96:e6874. [PMID: 28562536 PMCID: PMC5459701 DOI: 10.1097/md.0000000000006874] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Acute hyperammonemic encephalopathy induced by fluoropyrimidines (FPs) is a rare complication. Its pathophysiology remains unclear, especially given the currently used regimens, including intermediate-doses of 5-fluorouracil (5-FU) or oral FP agents. We aimed to characterize the clinical manifestations in cancer patients who developed hyperammonemic encephalopathy after receiving FP-based chemotherapy.We retrospectively reviewed 1786 patients with gastrointestinal or primary-unknown cancer who received FP-based regimens between 2007 and 2012. Eleven patients (0.6%) developed acute hyperammonemic encephalopathy. The incidence according to the administered anticancer drugs were as follows: 5-FU (8 of 1176, 0.7%), S-1 (1 of 679, 0.1%), capecitabine (2 of 225, 0.9%), and tegafur-uracil (UFT) (0 of 39, 0%). Ten patients (90.9%) had at least 1 aggravating factor, including infection, dehydration, constipation, renal dysfunction, and muscle loss. All the 10 patients met the definition of sarcopenia. Median time to the onset of hyperammonemic encephalopathy in the cycle was 3 days (range: 2-21). Three patients (27.3%) developed encephalopathy during the first cycle of the regimen and the remaining 8 patients during the second or more cycles. Seven patients (63.6%) had received at least 1 other FP-containing regimen before without episodes of encephalopathy.All patients recovered soon after immediate discontinuation of chemotherapy and supportive therapies, such as hydration, infusion of branched-chain amino acids, and oral lactulose intake, with a median time to recovery of 2 days (range: <1-7). Four patients (36.4%) received FP-based regimens after improvement of symptoms; 3 patients were successfully managed with dose reduction, and 1 patient, who had developed encephalopathy due to S-1 monotherapy, received modified FOLFOX-6 therapy without encephalopathy later.FP-associated acute hyperammonemic encephalopathy is extremely rare, but a possible event at any time and even during the administration of oral FP agents. Particular attention is warranted when giving FP-based therapy for patients with aggravating factors, such as sarcopenia. This complication can be properly managed with early detection.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yozo Sato
- Department of Diagnostic and Interventional Radiology
| | | | | | - Makoto Ishihara
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
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23
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Quirino M, Rossi S, Schinzari G, Basso M, Strippoli A, Cassano A, Barone C. Unexpected side effect in mCRC: A care-compliant case report of regorafenib-induced hyperammonemic encephalopathy. Medicine (Baltimore) 2017; 96:e6522. [PMID: 28422839 PMCID: PMC5406055 DOI: 10.1097/md.0000000000006522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Regorafenib represents a treatment option in heavily pretreated patients affected by metastatic colorectal cancer (mCRC). Its safety profile is typical of small-molecule tyrosine-kinase inhibitors (TKIs) and most adverse events are manageable. PATIENT CONCERNS A 56 years-old Caucasian man affected by mCRC with normal hepatic reserve was treated with regorafenib as second-line treatment. After only 2 days of therapy, the patient presented to the emergency department due to impairment of both spatial and temporal orientation and motor function with bradylalia. INTERVENTIONS Serum ammonia level was 191 mmol/L, liver function tests and complete blood count were normal. Regorafenib was withheld and branched chain amino acids and lactulose were administered. OUTCOMES Serum ammonia level returned within the normal range, but when regorafenib was restarted at a lower dose level, a new episode of acute confusion arised. MAIN LESSON Discontinuation of regorafenib after confirmation of hyperammonemia is strongly recommended; reintroduction of the therapy at lower doses after resolution of symptoms related to hyperammonemic encephalopathy has to be discouraged.
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Affiliation(s)
- Michela Quirino
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Sabrina Rossi
- Department of Medical Oncology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Giovanni Schinzari
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Michele Basso
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Antonia Strippoli
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Alessandra Cassano
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
| | - Carlo Barone
- Department of Medical Oncology, Catholic University of Sacred Heart, Rome
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24
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Sato K, Arai N, Omori A, Hida A, Kimura A, Takeuchi S. Hyperammonaemia and associated factors in unprovoked convulsive seizures: A cross-sectional study. Seizure 2016; 43:6-12. [PMID: 27768938 DOI: 10.1016/j.seizure.2016.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 08/20/2016] [Accepted: 09/28/2016] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Hyperammonaemia is frequently observed in patients who have experienced convulsive seizures. Although excessive muscle contraction is presumed to be responsible for the elevated levels of ammonia, the underlying mechanism is poorly understood. The present study aimed to identify the independent factors associated with ammonia elevation using large-scale multivariate analysis. METHODS We conducted a cross-sectional study involving 379 adult patients who had been transported to our emergency department and treated for unprovoked convulsive seizures between August 2010 and September 2015. Elevation of venous plasma ammonia levels was set as the primary endpoint, and patients' clinical and laboratory data were obtained. Those with severe liver dysfunction, known hepatic encephalopathy, or convulsions due to cardiovascular or psychogenic causes, and those taking valproate were excluded. RESULTS Using a cut-off value of 50μg/dL, 183 patients (48.3%) were found to have elevated levels of plasma ammonia. Four factors were identified as independent variables associated with hyperammonaemia following seizures: elevated venous lactate, lowered venous pH, sex (male), and longer duration of convulsion. CONCLUSIONS The results of the present study revealed independent factors associated with hyperammonaemia following unprovoked convulsive seizures in a larger scale and with more plausible statistical analysis. The authors further suggest that the excessive skeletal muscle contraction and/or respiratory failure during/after convulsive seizure may be the primary mechanism of hyperammonaemia.
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Affiliation(s)
- Kenichiro Sato
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Noritoshi Arai
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
| | - Aki Omori
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Ayumi Hida
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Akio Kimura
- Department of Emergency Medicine and Critical Care, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
| | - Sousuke Takeuchi
- Department of Neurology, Center Hospital of the National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan
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25
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Chiu CG, Zaghiyan KN, Silberman AW. Hyperammonemic Encephalopathy Associated With GI Stromal Tumor. J Clin Oncol 2016; 34:e51-3. [PMID: 24982462 DOI: 10.1200/jco.2013.48.9302] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Connie G Chiu
- Cedars-Sinai Medical Center, Los Angeles; John Wayne Cancer Institute, Santa Monica, CA
| | - Karen N Zaghiyan
- Cedars-Sinai Medical Center, Los Angeles; John Wayne Cancer Institute, Santa Monica, CA
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Yamada T, Kan H, Matsumoto S, Koizumi M, Shinji S, Matsuda A, Yamagishi A, Yokoyama Y, Takahashi G, Iwai T, Uchida E. Rechallenge with 5-fluorouracil in a patient who developed encephalopathy caused by 5-fluorouracil for colon cancer. Int Cancer Conf J 2016; 5:131-135. [PMID: 31149440 DOI: 10.1007/s13691-016-0243-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/09/2016] [Indexed: 10/22/2022] Open
Abstract
We report a case involving a patient with colon cancer who underwent 5-fluorouracil (5-FU) rechallenge and maintained an oncological effect for a long period after encephalopathy caused by 5-FU. Our patient was a 61-year-old man who was diagnosed with adenocarcinoma of the ascending colon with direct liver invasion. He underwent right hemicolectomy with partial liver resection followed by adjuvant chemotherapy with modified FOLFOX6 (mFOLFOX6). Ten months after completion of mFOLFOX6, his carcinoembryonic antigen concentration increased, and ascites was revealed by computed tomography 2 months later. We started FOLFIRI, and he was taken to our hospital by ambulance because of loss of consciousness 10 days after the start of the third cycle of FOLFIRI. Laboratory investigations showed hyperammonemia and elevations of his serum creatinine and blood urea nitrogen concentrations. Brain computed tomography demonstrated no abnormalities. Transfusion of 1500 ml of crystalloid fluid resulted in gradual recovery over the next 12 h. His ammonia concentration decreased to a normal level. Twelve days after onset of the encephalopathy, we restarted FOLFIRI, but the dose of continuous 5-FU was decreased by 20 %. The patient's carcinoembryonic antigen concentration considerably decreased from 376.5 to 19.9 ng/ml, and his ascites disappeared. Nineteen months after the resumption of FOLFIRI, he underwent 34 courses of FOLFIRI and maintained stable disease. The encephalopathy did not recur.
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Affiliation(s)
- Takeshi Yamada
- 1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, 113-8603 Japan
| | - Hayato Kan
- 1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, 113-8603 Japan
| | - Satoshi Matsumoto
- 2Department of Surgery, Nippon Medical School, Chiba Hokuso Hospital, Tokyo, 113-8603 Japan
| | - Michihiro Koizumi
- 1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, 113-8603 Japan
| | - Seiichi Shinji
- 1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, 113-8603 Japan
| | - Akihisa Matsuda
- 2Department of Surgery, Nippon Medical School, Chiba Hokuso Hospital, Tokyo, 113-8603 Japan
| | - Aya Yamagishi
- 1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, 113-8603 Japan
| | - Yasuyuki Yokoyama
- 1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, 113-8603 Japan
| | - Goro Takahashi
- 1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, 113-8603 Japan
| | - Takuma Iwai
- 1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, 113-8603 Japan
| | - Eiji Uchida
- 1Department of Gastrointestinal and Hepato-Biliary-Pancreatic Surgery, Nippon Medical School, Tokyo, 113-8603 Japan
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Maruyama M, Miyasaka Y, Takano A, Inoue M, Furuya K, Sugai H, Hada M, Nakagomi H. A case of advanced rectal cancer with rectovesical and ileal fistulae that developed hyperammonemic encephalopathy. Surg Case Rep 2015; 1:88. [PMID: 26435908 PMCID: PMC4582075 DOI: 10.1186/s40792-015-0088-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 09/14/2015] [Indexed: 11/22/2022] Open
Abstract
Hyperammonemic encephalopathy is rarely caused by a urinary diversion. We herein experienced a case of rectal carcinoma with rectovesical and ileal fistulae that developed hyperammonemic encephalopathy. A 72-year-old man suffered from a fever, diarrhea, pneumaturia, and fecaluria beginning in April 2013 and was referred to our hospital in May 2013. He developed a loss of consciousness and whole body cramping on the first hospital day. The laboratory data indicated an inflammatory reaction and hyperammonemia with a highly elevated serum ammonia (NH3) level of 703 μg/dl. The patient was diagnosed to have rectal carcinoma with rectovesical and ileal fistulae according to computed tomography (CT) and a water-soluble contrast enema. We administered a solution of branched chain amino acids (BCAA) and antibiotics. Furthermore, we repeatedly irrigated bladder through the urethral catheter. The patient’s symptoms recovered, and the serum ammonia levels on the second and third hospital day were decreased to 210 and 135 μg/dl, respectively. However, the symptoms of infection and confusion were suspected to repeat; we elected to perform surgical treatment. An ileal disconnection with ileocecal bypass and sigmoidostomy were effective for preventing hyperammonemic encephalopathy.
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Affiliation(s)
- Masahiro Maruyama
- Department of Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, Japan
| | - Yoshiaki Miyasaka
- Department of Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, Japan
| | - Atsushi Takano
- Department of Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, Japan
| | - Masayuki Inoue
- Department of Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, Japan
| | - Kazushige Furuya
- Department of Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, Japan
| | - Hidemitsu Sugai
- Department of Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, Japan
| | - Masao Hada
- Department of Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, Japan
| | - Hiroshi Nakagomi
- Department of Surgery, Yamanashi Prefectural Central Hospital, Fujimi1-1-1, Kofu, Yamanashi, Japan
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Idiopathic Hyperammonemia That Developed During Initial Treatment With Steroid in a Patient With Newly Diagnosed Leukemia. J Pediatr Hematol Oncol 2015; 37:e361-3. [PMID: 25222063 DOI: 10.1097/mph.0000000000000255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Idiopathic hyperammonemia (IHA) has been described as a complication of intensive chemotherapy for the treatment of hematologic malignancy but has subsequently been found in patients undergoing bone marrow transplantation and in those with solid tumors treated with 5-fluorouracil. Although IHA is a rare complication, it is sometimes associated with high mortality in hematologic malignancies. Here we report the case of a 15-year-old boy in whom hyperammonemia developed during the initial treatment with prednisolone for newly diagnosed acute lymphoblastic leukemia and who survived after early detection and oral lactulose therapy. To the best of our knowledge, this is the first report of IHA that was not induced by intensive chemotherapy, stem cell transplantation, or asparaginase therapy in a patient with newly diagnosed leukemia, but developed during an initial treatment with a steroid. Early detection of IHA by measuring the plasma ammonia level in patients with neurological symptoms may improve the outcome.
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Laemmle A, Hahn D, Hu L, Rüfenacht V, Gautschi M, Leibundgut K, Nuoffer JM, Häberle J. Fatal hyperammonemia and carbamoyl phosphate synthetase 1 (CPS1) deficiency following high-dose chemotherapy and autologous hematopoietic stem cell transplantation. Mol Genet Metab 2015; 114:438-44. [PMID: 25639153 DOI: 10.1016/j.ymgme.2015.01.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 01/19/2015] [Accepted: 01/19/2015] [Indexed: 11/16/2022]
Abstract
Fatal hyperammonemia secondary to chemotherapy for hematological malignancies or following bone marrow transplantation has been described in few patients so far. In these, the pathogenesis of hyperammonemia remained unclear and was suggested to be multifactorial. We observed severe hyperammonemia (maximum 475 μmol/L) in a 2-year-old male patient, who underwent high-dose chemotherapy with carboplatin, etoposide and melphalan, and autologous hematopoietic stem cell transplantation for a neuroblastoma stage IV. Despite intensive care treatment, hyperammonemia persisted and the patient died due to cerebral edema. The biochemical profile with elevations of ammonia and glutamine (maximum 1757 μmol/L) suggested urea cycle dysfunction. In liver homogenates, enzymatic activity and protein expression of the urea cycle enzyme carbamoyl phosphate synthetase 1 (CPS1) were virtually absent. However, no mutation was found in CPS1 cDNA from liver and CPS1 mRNA expression was only slightly decreased. We therefore hypothesized that the acute onset of hyperammonemia was due to an acquired, chemotherapy-induced (posttranscriptional) CPS1 deficiency. This was further supported by in vitro experiments in HepG2 cells treated with carboplatin and etoposide showing a dose-dependent decrease in CPS1 protein expression. Due to severe hyperlactatemia, we analysed oxidative phosphorylation complexes in liver tissue and found reduced activities of complexes I and V, which suggested a more general mitochondrial dysfunction. This study adds to the understanding of chemotherapy-induced hyperammonemia as drug-induced CPS1 deficiency is suggested. Moreover, we highlight the need for urgent diagnostic and therapeutic strategies addressing a possible secondary urea cycle failure in future patients with hyperammonemia during chemotherapy and stem cell transplantation.
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Affiliation(s)
- Alexander Laemmle
- Division of Metabolism and Children's Research Center (CRC), University Children's Hospital, Zurich, Switzerland; Department of Pediatrics, University Children's Hospital, Bern, Switzerland.
| | - Dagmar Hahn
- University Institute of Clinical Chemistry, University of Bern, Switzerland.
| | - Liyan Hu
- Division of Metabolism and Children's Research Center (CRC), University Children's Hospital, Zurich, Switzerland.
| | - Véronique Rüfenacht
- Division of Metabolism and Children's Research Center (CRC), University Children's Hospital, Zurich, Switzerland.
| | - Matthias Gautschi
- Department of Pediatrics, University Children's Hospital, Bern, Switzerland; University Institute of Clinical Chemistry, University of Bern, Switzerland.
| | - Kurt Leibundgut
- Department of Pediatrics, University Children's Hospital, Bern, Switzerland.
| | - Jean-Marc Nuoffer
- Department of Pediatrics, University Children's Hospital, Bern, Switzerland; University Institute of Clinical Chemistry, University of Bern, Switzerland.
| | - Johannes Häberle
- Division of Metabolism and Children's Research Center (CRC), University Children's Hospital, Zurich, Switzerland.
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Nakamura K, Yamane K, Shinohara K, Doi K, Inokuchi R, Hiruma T, Nakajima S, Noiri E, Yahagi N. Hyperammonemia in idiopathic epileptic seizure. Am J Emerg Med 2013; 31:1486-9. [DOI: 10.1016/j.ajem.2013.08.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 07/28/2013] [Accepted: 08/03/2013] [Indexed: 01/09/2023] Open
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Hyperammonemia in review: pathophysiology, diagnosis, and treatment. Pediatr Nephrol 2012; 27:207-22. [PMID: 21431427 DOI: 10.1007/s00467-011-1838-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2010] [Revised: 01/09/2011] [Accepted: 01/12/2011] [Indexed: 12/31/2022]
Abstract
Ammonia is an important source of nitrogen and is required for amino acid synthesis. It is also necessary for normal acid-base balance. When present in high concentrations, ammonia is toxic. Endogenous ammonia intoxication can occur when there is impaired capacity of the body to excrete nitrogenous waste, as seen with congenital enzymatic deficiencies. A variety of environmental causes and medications may also lead to ammonia toxicity. Hyperammonemia refers to a clinical condition associated with elevated ammonia levels manifested by a variety of symptoms and signs, including significant central nervous system (CNS) abnormalities. Appropriate and timely management requires a solid understanding of the fundamental pathophysiology, differential diagnosis, and treatment approaches available. The following review discusses the etiology, pathogenesis, differential diagnosis, and treatment of hyperammonemia.
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Hung TY, Chen CC, Wang TL, Su CF, Wang RF. Transient hyperammonemia in seizures: a prospective study. Epilepsia 2011; 52:2043-9. [PMID: 21972984 DOI: 10.1111/j.1528-1167.2011.03279.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To investigate the incidence and duration of transient hyperammonemia in seizures and to verify the significant confounders related to transient hyperammonemia in seizures. METHODS One hundred twenty-one noncirrhotic adult patients with seizures admitted to the emergency department were enrolled in the study. Laboratory examination was performed, including plasma ammonia level assessment. In addition, the basic parameters, underlying systemic diseases, and seizure-related conditions were assessed. The patients were classified into a group with hyperammonemia on arrival and a group without, in order to compare seizure-related adverse events that occurred during a 9-month period. KEY FINDINGS The incidence of hyperammonemia in patients with seizures was 67.77%. Plasma ammonia levels in patients with generalized tonic-clonic (GTC) seizures were significantly higher than those in patients in the non-GTC seizure group (median 174.5 vs. 47 μg/dl; proportion 76.5% vs. 21.1%; p < 0.001). Median plasma ammonia levels decreased spontaneously from 250 to 54 μg/dl (p < 0.00001) in an average interval of 466.79 min. GTC seizures (p < 0.0001), male gender (p < 0.0001), bicarbonate (p < 0.0001), diabetes (p = 0.0139), and alcohol-related seizures (p = 0.0002) were significant factors associated with hyperammonemia on arrival. No significant differences related to admission rates or mortalities were found between the two groups. SIGNIFICANCE The presence of transient hyperammonemia in patients with seizures is significantly related to GTC seizures, male gender, bicarbonate, diabetes, and alcohol-related seizures. The appropriate period to study ammonia levels following a seizure event is within 8 h. Because these phenomena are self-limited, ammonia-lowering management are not necessary. Hyperammonemia on arrival is not necessarily related to adverse outcomes.
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Affiliation(s)
- Tzu-Yao Hung
- Emergency Department, Keelung Hospital, Department of Health, Executive Yuan, Keelung, Taiwan
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Abstract
Adult hyperammonaemia is associated with severe liver disease in 90% of cases. In the remainder, noncirrhotic causes should be considered. Measurements of serum ammonia level must be part of the basic work-up in all patients presenting with encephalopathy of unknown origin, even when liver function is normal. Clinician awareness of noncirrhotic hyperammonaemic encephalopathy can contribute to early diagnosis and the initiation of sometimes life-saving treatment. This review focuses on the physiology, aetiology and underlying mechanisms of noncirrhotic hyperammonaemic encephalopathy and discusses the available treatment modalities.
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Affiliation(s)
- Ido Laish
- Department of Internal Medicine A and Rabin Medical Center, Beilinson Hospital, Petah Tiqwa, Israel
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Akitake R, Miyamoto S, Nakamura F, Horimatsu T, Ezoe Y, Muto M, Chiba T. Early Detection of 5-FU-induced Acute Leukoencephalopathy on Diffusion-Weighted MRI. Jpn J Clin Oncol 2010; 41:121-4. [DOI: 10.1093/jjco/hyq157] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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35
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Metzeler KH, Boeck S, Christ B, Hausmann A, Stemmler HJ, Parhofer KG, Ostermann H, Hiddemann W, Braess J. Idiopathic hyperammonemia (IHA) after dose-dense induction chemotherapy for acute myeloid leukemia: Case report and review of the literature. Leuk Res 2009; 33:e69-72. [DOI: 10.1016/j.leukres.2009.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 01/07/2009] [Accepted: 01/14/2009] [Indexed: 01/09/2023]
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36
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Turken O, Basekim C, Haholu A, Karagoz B, Bilgi O, Ozgun A, Kucukardali Y, Narin Y, Yazgan Y, Kandemir EG. Hyperammonemic encephalopathy in a patient with primary hepatic neuroendocrine carcinoma. Med Oncol 2008; 26:309-13. [PMID: 19031017 DOI: 10.1007/s12032-008-9121-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2008] [Accepted: 10/21/2008] [Indexed: 01/09/2023]
Abstract
A 53-year-old male patient was admitted to our hospital with abdominal pain in the right upper quadrant. There was no change in laboratory investigations other than a slight increase in serum levels of alkaline phosphatase (ALP), alanine aminotransferase (ALT), and gamma glutamyl transferase (GGT). Computed tomography (CT) of the abdomen showed multiple hepatic nodular lesions in the liver. Tru-cut biopsy of the lesions was reported as well-differentiated neuroendocrine carcinoma. The patient received sandostatin treatment. After a few days, the patient was hospitalized in the intensive care unit with disturbance of consciousness and clinical features suggestive of encephalopathy. Serum ammonia level was found highly elevated. After the treatment with L-ornithine-L-aspartate, a remarkable improvement in the level of patient's sensorium occurred as well as a reduction in serum ammonia level within a few days. Transarterial chemoembolization (TACE) was performed one week later. The patient's condition began to worsen along with increase in serum ammonia level and he died because of hyperammonemic encephalopathy. There are case reports of hyperammonemia with some malignancies such as multiple myeloma, plasma cell leukemia, and leiomyosarcoma, or in some patients who have received chemotherapy. This case may suggest an association between hyperammonemia and neuroendocrine tumors.
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Affiliation(s)
- Orhan Turken
- Medical Oncology Department, GATA Haydarpasa Training Hospital, Haydarpasa, Uskudar, Istanbul, Turkey.
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Nott L, Price TJ, Pittman K, Patterson K, Young R, Fletcher J. Hyperammonaemic encephalopathy associated with rituximab-containing chemotherapy. Intern Med J 2008; 38:800-3. [DOI: 10.1111/j.1445-5994.2008.01772.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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38
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Kikuta S, Asakage T, Nakao K, Sugasawa M, Kubota A. The aggravating factors of hyperammonemia related to 5-fluorouracil infusion—A report of two cases. Auris Nasus Larynx 2008; 35:295-9. [PMID: 17826933 DOI: 10.1016/j.anl.2007.04.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2006] [Revised: 03/09/2007] [Accepted: 04/22/2007] [Indexed: 11/23/2022]
Abstract
Hyperammonemia or hyperammonemic leukoencephalopathy sometimes occurs as an adverse event after 5-fluorouracil (5-FU) chemotherapy. The actual mechanism responsible for hyperammonemia by 5-FU administration is not known. Patient 1, a 48-year-old woman with cervical esophageal squamous cell carcinoma (SCC) presented with transient hyperammonemic leukoencephalopathy after undergoing combined chemotherapy (750mg/body/day of 5-FU for 5 days+100mg/body/day of cisplatin). Patient 2, a 58-year-old man with oropharyngeal and lower esophageal SCCs presented with hyperammonemia without leukoencephalopathy while undergoing combined chemotherapy (1200mg/body/day of 5-FU for 5 days+120mg/body/day of cisplatin). The neural symptoms of both patients improved after the termination of 5-FU administration and the early administration of fluid replacement. Ammonia can accumulate in the body when catabolism is insufficient because of an impairment in the urea cycle. The excess production of ammonium from 5-FU catabolites in addition to aggravating factors, e.g., renal dysfunction, constipation and body weight loss, may explain the transient hyperammonemia seen in the present two cases. The incidence of hyperammonemia by 5-FU administration will be one of the adverse events to need care in future and may be decreased by being aware of the presence of renal dysfunction, taking measures to prevent constipation, and nutritional management.
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Affiliation(s)
- Shu Kikuta
- Department of Otolaryngology, Faculty of Medicine, University of Tokyo,7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
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Nott L, Price TJ, Pittman K, Patterson K, Fletcher J. Hyperammonemia encephalopathy: an important cause of neurological deterioration following chemotherapy. Leuk Lymphoma 2007; 48:1702-11. [PMID: 17786705 DOI: 10.1080/10428190701509822] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Idiopathic hyperammonemic encephalopathy is an uncommon but frequently fatal complication of chemotherapy. It is characterised by abrupt alteration in mental status with markedly elevated plasma ammonia levels in the absence of obvious liver disease or any other identifiable cause, and frequently results in intractable coma and death. It usually occurs in patients with haematologic malignancies during the period of neutropenia following cytoreductive therapy or bone marrow transplantation, and in solid organ malignancies treated with 5-fluorouracil. Although the aetiology of this syndrome is yet to be determined, it appears to be multi-factorial in nature. Optimal management remains to be formally established, and the critical step is increased awareness of the syndrome by measurement of plasma ammonium levels in patients with neurological symptoms, leading to early diagnosis and the prompt implementation of therapy.
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Affiliation(s)
- Louise Nott
- Department of Oncology, The Queen Elizabeth Hospital, Woodville, Australia
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40
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Heluwaert F, Santre C, Martin C, Hilleret MN, Martin D. [Coma following chemotherapy: is 5FU implicated? Discussion about on case-report]. ACTA ACUST UNITED AC 2006; 30:325-6. [PMID: 16565673 DOI: 10.1016/s0399-8320(06)73176-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
5FU is one of the most frequently used antioncogenic and cytostatic drug in digestive oncology. It may cause severe adverse events, such as encephalopathy, possibly based on hyperammoniemia, and may lead to coma. We report here the case of a coma with a favorable outcome following 5FU chemotherapy. As any other etiologic findings came to light, hyperammoniemia was discussed as a credible cause.
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41
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Kim YA, Chung HC, Choi HJ, Rha SY, Seong JS, Jeung HC. Intermediate dose 5-fluorouracil-induced encephalopathy. Jpn J Clin Oncol 2006; 36:55-9. [PMID: 16436463 DOI: 10.1093/jjco/hyi214] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
As an acute neurotoxicity, high dose 5-fluorouracil (5-FU)-induced encephalopathy is well-known, but encephalopathy associated with lower dose is rarely reported. Here, we report a case of a male with anal cancer who was treated with 5-FU 1000 mg/m(2), continuous infusion for 5 days q4 weeks. At the second and the fourth cycles of chemotherapy, sudden confusion, cognitive dysfunction and disorientation occurred during 5-FU infusion. They were accompanied by hyperammonemia in the absence of focal neurological deficits or structural abnormalities. These symptoms completely disappeared and the serum ammonia level returned to normal after discontinuation of 5-FU and conservative care. In order to investigate a possible deficit of dihydropyrimidine dehydrogenase (DPD), we checked its mRNA level before and after treatment using real-time PCR. The patient's pre-treatment level was 80% compared with reference group, and it was elevated up to 187% of initial after 5-FU treatment, implying that that his encephalopathy may be 5-FU catabolite type rather than DPD deficiency. In conclusion, we report that encephalopathy can develop even with the dose of 5-FU lower than ever reported, and it should be considered as a differential diagnosis for proper management.
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Affiliation(s)
- Yeon-A Kim
- Department of Internal Medicine, Yonsei Cancer Center, Seoul, Korea
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42
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Guilloton L, Michaud A, Potier V, Le Berre J, Drouet A, Felten D. Ataxie et confusion après traitement par 5-fluorouracile. Rev Med Interne 2005; 26:986-7. [PMID: 16337869 DOI: 10.1016/j.revmed.2005.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2005] [Accepted: 02/21/2005] [Indexed: 11/21/2022]
Affiliation(s)
- L Guilloton
- Service de neurologie, HIA Desgenettes, 108, boulevard Pinel 69275 Lyon cedex 03, France.
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Abstract
5-fluorouracil (5-FU)-associated peripheral neuropathy is an uncommon event. Capecitabine (CAP) is a pro-drug of 5-FU and peripheral neuropathy associated with CAP has not been reported. During analysis of 28 patients receiving CAP with concomitant radiation (XRT) for pancreatic cancer (resected or locally advanced), two patients developed signs and symptoms consistent with peripheral neuropathy. Patients received CAP 1200-1600 mg/m2 in two divided doses with XRT (total 5040-5400 Gy) x 6 weeks, followed by 4 weeks rest, then 6 cycles of CAP 2000-2500 mg/m2 in two divided doses x 14 days every (q) 3 weeks. Patients were assessed weekly during CAP-XRT and q 3 weeks during CAP alone. Patient A reported right leg weakness (foot drop) during week 4 of CAP-XRT (1600 mg/m2). Patient B developed perioral and upper extremity paresthesias during the fourth cycle of CAP alone (2500 mg/m2). Dihydropyrimidine dehydrogenase (DPD) activity was measured by radioisotopic assay using lysates of peripheral blood mononuclear cells. Neurologic examination revealed right foot drop in Patient A and was unremarkable in Patient B. Central nervous system imaging was negative. Electromyogram and nerve conduction studies showed sensorimotor peripheral neuropathy in both patients. DPD activity was normal in both patients. There was no evidence of disease progression. Neurologic symptoms resolved after stopping CAP for 4 weeks in Patient A, with no recurrence after reinitiating CAP alone at 2000 mg/m2. Patient B continued at 80% of standard dose (2000 mg/m2) and symptoms resolved without further intervention. We conclude peripheral neuropathy with 5-FU is rare. Neurotoxicity occurs most often with intermittent high dose 5-FU as bolus injection or 24- to 48-h infusions. The etiology of neurotoxicity in our two patients remains unclear; however, as CAP is rapidly metabolized to 5-FU in patients with normal liver function, it is likely that 5-FU or its active metabolites (fluoro-beta-alanine) were contributing factors. Knowledge regarding potential adverse effects of CAP is paramount and dose modification is indicated with development of neurotoxicity.
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Affiliation(s)
- M Wasif Saif
- University of Alabama at Birmingham, Comprehensive Cancer Center, Birmingham, AL 35294-3300, USA.
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44
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Saif MW, Wilson RH, Harold N, Keith B, Dougherty DS, Grem JL. Peripheral neuropathy associated with weekly oral 5-fluorouracil, leucovorin and eniluracil. Anticancer Drugs 2001; 12:525-31. [PMID: 11459999 DOI: 10.1097/00001813-200107000-00006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
5-Fluorouracil (5-FU)-associated neurotoxicity is uncommon; symptoms may occur abruptly or more gradually during the course of chemotherapy. Peripheral neuropathy with 5-FU therapy has only rarely been reported. Two patients treated in a phase I trial of oral 5-FU, leucovorin and eniluracil, an inhibitor of dihydropyrimidine dehydrogenase (DPD), developed delayed onset symptoms of unsteady gait and reduced sensation in the legs. Magnetic resonance imaging scans of the brain and neurologic examination did not support a CNS basis for the condition. Electromyograms and nerve conduction studies revealed sensorimotor polyneuropathy. Other common etiologies of peripheral neuropathy were excluded. The neurological condition of these patients stabilized after 5-FU dose reduction and partial resolution gradually occurred when protocol therapy was stopped. Although CNS symptoms may rarely complicate 5-FU therapy, peripheral neuropathy is unexpected. Patients with DPD deficiency treated with conventional doses of 5-FU typically develop acute CNS toxicity shortly after therapy, accompanied by extremely high systemic exposure to 5-FU. Patients with normal 5-FU clearance may also experience CNS toxicity, particularly with high-dose schedules, and both parent drug and its catabolites may be contributory. Since DPD was profoundly inhibited during eniluracil therapy in these two patients, it is likely that 5-FU or its active metabolites were contributing factors to the peripheral neuropathy.
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Affiliation(s)
- M W Saif
- Developmental Therapeutics Department, Medicine Branch, Division of Clinical Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD 20889, USA
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