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Lei CL, Gui XL, Wang LY, Guo YJ, Li Y. Analysis of drug-induced posterior reversible encephalopathy syndrome using the food and drug administration adverse drug events reporting system database. Expert Opin Drug Saf 2024; 23:607-616. [PMID: 38478961 DOI: 10.1080/14740338.2024.2327510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/03/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE In this retrospective pharmacovigilance study, we gathered data on drug-induced posterior reversible encephalopathy syndrome (PRES). Our goal was to identify the primary suspect drugs in PRES by analyzing the Food and Drug Administration Adverse Events Reporting System (FAERS) database. METHODS We identified and analyzed reports of PRES listed in the FAERS database between 2004 and 2021. Using the reporting odds ratio and 95% confidence interval, we evaluated the safety signals for each of the drugs associated with PRES. RESULTS We reviewed 11,077 reports of adverse events corresponding to PRES. The primary suspect drug categories were antineoplastics, immunosuppressants, and glucocorticoids. PRES was 24.77% more likely to occur in females than in males. Drug-induced PRES usually occurs in individuals with cancer, those who have undergone an organ/stem cell transplant, and those with autoimmune conditions. CONCLUSION Our results show that the drugs most commonly suspected to cause PRES were antineoplastics, immunosuppressants, and glucocorticoids. Future studies are needed to illuminate the pathophysiological alterations that underlie PRES. In the meantime, prescribers and patients should be made aware of the potential risks of PRES associated with pharmaceutical therapy, and the summaries of product characteristics for individual drugs should be updated to include this information.
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Affiliation(s)
- Cai-Lu Lei
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
- School of Pharmaceutical Science, Guangxi Medical University, Nanning, China
| | - Xiao-Long Gui
- Department of Gastrointestinal & Gland Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Lin-Yu Wang
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
| | - You-Jia Guo
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Yan Li
- Department of Pharmacy, Guangxi Medical University Cancer Hospital, Nanning, China
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Evin C, Lassau N, Balleyguier C, Assi T, Ammari S. Posterior Reversible Encephalopathy Syndrome Following Chemotherapy and Immune Checkpoint Inhibitor Combination in a Patient with Small-Cell Lung Cancer. Diagnostics (Basel) 2022; 12:diagnostics12061369. [PMID: 35741179 PMCID: PMC9221884 DOI: 10.3390/diagnostics12061369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/18/2022] [Accepted: 05/30/2022] [Indexed: 12/10/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare neurological complication that occurs following a sudden blood pressure increase. We report the case of a 64-year-old patient presenting PRES several hours after the administration of a combination of chemotherapy and a checkpoint inhibitor (carboplatin-etoposide-atezolizumab) for small-cell lung cancer. He presented consciousness disorders associated with partial epileptic seizure secondarily generalized. His arterial blood pressure was elevated and brain imaging showed multiple bilateral subcortical parietal, temporal, occipital and cerebellar T2 high signals, predominantly in the posterior region. There were no abnormal T1 signals nor bleeding but a left apparent diffusion coefficient restriction was noted. On arterial spin labelling perfusion sequences, there was an increased perfusion within the left temporo-parieto-occipital, left thalamic and right cerebellar regions. Finally, the neurological symptoms completely regressed after several days of optimal antihypertensive and antiepileptic treatment. The clinical context and radiological features, as well as the progressive resolution of the neurological symptoms, were all in favor of PRES. PRES can occur after the administration of chemotherapy and/or immunotherapy. Prompt diagnosis is crucial through a spectrum of suspicious clinical and radiological characteristics that must be rapidly recognized to quickly anticipate the optimal therapeutic strategy and avoid unnecessary complications.
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Affiliation(s)
- Cécile Evin
- Department of Imaging, Gustave Roussy, Université Paris-Saclay, 94805 Villejuif, France; (C.E.); (N.L.); (C.B.)
| | - Nathalie Lassau
- Department of Imaging, Gustave Roussy, Université Paris-Saclay, 94805 Villejuif, France; (C.E.); (N.L.); (C.B.)
- Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris-Saclay, 94805 Villejuif, France
| | - Corinne Balleyguier
- Department of Imaging, Gustave Roussy, Université Paris-Saclay, 94805 Villejuif, France; (C.E.); (N.L.); (C.B.)
- Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris-Saclay, 94805 Villejuif, France
| | - Tarek Assi
- Department of Oncology, Gustave Roussy, Université Paris-Saclay, 94805 Villejuif, France;
| | - Samy Ammari
- Department of Imaging, Gustave Roussy, Université Paris-Saclay, 94805 Villejuif, France; (C.E.); (N.L.); (C.B.)
- Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris-Saclay, 94805 Villejuif, France
- Correspondence:
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Song CH, Lee SJ, Jeon HR. Posterior reversible encephalopathy syndrome in a patient with metastatic breast cancer: A case report. World J Clin Cases 2022; 10:2281-2285. [PMID: 35321170 PMCID: PMC8895189 DOI: 10.12998/wjcc.v10.i7.2281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/05/2021] [Accepted: 01/25/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a neurotoxic encephalopathic state with clinical symptoms such as headache, altered consciousness, visual disturbances, and seizures. Vasogenic edema occurs predominantly in the posterior occipital and parietal lobes of the brain. PRES is caused by various diseases, and its mechanism remains unclear. However, it can be easily diagnosed based on characteristic lesions on magnetic resonance imaging.
CASE SUMMARY A 51-year-old woman with unremarkable past medical history presented with progressively worsening back pain since 2 mo. Physical examinations revealed paralumbar muscle tenderness, a large lesion on the right breast and several mass-like lesions on both breasts. The blood pressure (BP) was elevated (150/90 mmHg), and did not respond to antihypertensive medication. On the seventh day of hospitalization, she exhibited a confused mental status and generalized tonic-clonic seizures. On magnetic resonance imaging, bilateral cortical and subcortical edema of the occipital lobes, suggestive of PRES, was observed. The serum calcium was 15.8 mg/dL. After two days of treatment with nicardipine, elcatonin, and zolendronic acid, her BP was 130/91 mmHg and serum calcium was 10.1 mg/dL. The patient regained consciousness and her mental status improved. Fluorodeoxyglucose-positron emission tomography revealed right breast cancer with extensive metastases.
CONCLUSION Although rare, hypercalcemia can lead to PRES by causing uncontrolled hypertension. Prompt diagnosis can help prevent severe mental disturbances and even death.
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Affiliation(s)
- Chae Hyun Song
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang-si Gyeonggi-do 10444, South Korea
| | - Seung Jun Lee
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang-si Gyeonggi-do 10444, South Korea
| | - Ha Ra Jeon
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang-si Gyeonggi-do ASI/KR/KS009/Goyang, South Korea
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Holroyd KB, Rubin DB, Vaitkevicius H. Neurologic Complications in Patients with Cancer. Semin Neurol 2021; 41:588-605. [PMID: 34619783 DOI: 10.1055/s-0041-1733788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurologic symptoms are commonly seen in patients with cancer and can be among the most challenging to diagnose and manage. It is often difficult to determine if new neurologic symptoms are secondary to direct effects of a malignant lesion, systemic complications of disease, paraneoplastic disorders, or side effects of cancer treatment itself. However, early diagnosis and treatment of each of these conditions can improve patients' quality of life and long-term functional outcomes. In this review, we describe a systematic approach to the diagnosis of new neurologic symptoms in patients with known malignancy. We have categorized the neurologic complications of cancer through a mechanistic approach, with an emphasis on ascertaining underlying pathophysiology to guide treatment choice. This review focuses on the acute neurologic complications of cancer that require hospital admission.
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Affiliation(s)
| | - Daniel B Rubin
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts
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Winter SF, Jo J, Schiff D, Dietrich J. Central Nervous System Complications Among Oncology Patients. Hematol Oncol Clin North Am 2021; 36:217-236. [PMID: 34607715 DOI: 10.1016/j.hoc.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Cancer treatment related injury to the central nervous system (CNS) is well-recognized in the setting of brain-directed radiation therapies and conventional and novel systemic anticancer therapies. Late-delayed treatment-induced CNS complications frequently result in permanent neurologic disability. Therapeutic options are supportive with limited clinical benefit, whereby alteration or discontinuation of the overall antineoplastic treatment plan is frequently necessary to prevent further neurologic injury. Better identification of patients at high risk for developing late CNS toxicities, neuroprotective strategies with modification of existing antineoplastic treatment regimens, and research efforts directed at earlier recognition and improved treatment of central neurologic complications are paramount.
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Affiliation(s)
- Sebastian F Winter
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Neurology and Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Jasmin Jo
- Division of Hematology and Oncology, Department of Internal Medicine, East Carolina University, 600 Moye Boulevard, Greenville, NC 27858-4353, USA
| | - David Schiff
- Division of Neuro-Oncology, Department of Neurology, University of Virginia, 1240 Lee Street, Charlottesville, VA 22903, USA.
| | - Jorg Dietrich
- Department of Neurology and MGH Cancer Center, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 9E, Boston, MA 02114, USA.
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Miller R, Wagner S, Hammond J, Roberts N, Marshall K, Barth B. Posterior reversible encephalopathy syndrome in the emergency department: A single center retrospective study. Am J Emerg Med 2021; 45:61-64. [PMID: 33667750 DOI: 10.1016/j.ajem.2021.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/05/2021] [Accepted: 02/05/2021] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Posterior Reversible Encephalopathy Syndrome (PRES) and the related term Reversible Posterior Leukoencephalopathy Syndrome (RPLS) denote a constellation of clinical symptoms paired with key radiological findings. These symptoms may include headache, altered mental status, visual changes, and seizures. PRES is a rare condition and remains a challenging diagnosis to make in the emergency department. Data on risk factors and clinical presentation are limited, and there is no recent literature-supported diagnostic criteria. Our primary objective was to identify initial symptoms, clinical presentation, and risk factors that should guide the emergency clinician to consider a diagnosis of PRES. A secondary objective was to identify associations between risk factors and the outcomes of mortality and ICU admissions. METHODS This was a retrospective, observational study that evaluated patients seen in the Emergency Department (ED) in an urban tertiary care center with the diagnosis of PRES or RPLS from 1/1/2008 to 1/1/2018. The Health System's Electronic Medical Record was used to collect data. Search criteria included any patient diagnosed with Posterior Reversible Encephalopathy Syndrome (PRES) or Reversible Posterior Leukoencephalopathy Syndrome (RPLS), and excluded patients under 18 years of age, transfer patients, or patients that were not evaluated in our emergency department. RESULTS We identified 98 patients based on our initial search criteria. After a chart review, 27 patients met our predefined eligibility criteria. In patients with confirmed diagnosis of PRES, the majority were female (70%) and 37% were either on an immunomodulator or undergoing chemotherapy at the time of presentation. 67% of patients presented with altered mental status, 41% had a focal neurologic deficit, and 37% had a witnessed seizure prior to diagnosis. Headache (48%), nausea (33%), and vision changes (30%) were the next most common reported symptoms. The majority of patients were hypertensive at time of presentation (82%) and many had a past medical history of hypertension (78%); twelve were given anti-hypertensive medications. 33% of the patients were admitted to the ICU and 26% died. There were no statistical associations found between documented ED interventions and the outcome of mortality. CONCLUSION PRES is difficult to identify and diagnose in the emergency department. Significant risk factors such as female gender, hypertension, and those currently undergoing active immunotherapy/chemotherapy are associated with PRES. Common presenting complaints and exam findings include headache, altered mental status, and neurologic deficits. Emergency providers should consider PRES in patients presenting with altered mental status with significant risk factors, especially with neurologic deficits for which stroke has been ruled out.
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Affiliation(s)
- Ross Miller
- University of Kansas Medical Center, Kansas City, KS, USA.
| | - Samuel Wagner
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Jordan Hammond
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Nathan Roberts
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Ken Marshall
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Bradley Barth
- University of Kansas Medical Center, Kansas City, KS, USA
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Kaur G, Ashraf I, Peck MM, Maram R, Mohamed A, Ochoa Crespo D, Malik BH. Chemotherapy and Immunosuppressant Therapy-Induced Posterior Reversible Encephalopathy Syndrome. Cureus 2020; 12:e11163. [PMID: 33251070 PMCID: PMC7688184 DOI: 10.7759/cureus.11163] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 10/25/2020] [Indexed: 11/25/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an entity which is characterized by acute to subacute onset of neurological symptoms like altered mental status, seizures, headaches and other focal neurological deficits. It is diagnosed with the help of MRI findings which typically involve the subcortical white matter of parieto-occipital lobes. In this review, we will discuss the various etiologies and risk factors including some of the most common chemotherapeutic agents and immunosuppressant agents associated with this disorder. We will discuss the mechanism of actions and side effect profiles of a few drugs and their role in causation of PRES. This review article discusses if there is any difference in presentation and imaging findings of PRES caused by cytotoxic agents versus caused by other etiologies. It also highlights the difficulty in management of PRES caused by cytotoxic agents as the discontinuation of these drugs could be life-threatening due to graft rejections or graft versus host disease.
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Affiliation(s)
- Gurleen Kaur
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ibtisam Ashraf
- Internal Medicine, Shalamar Institute of Health Sciences, Lahore, PAK
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mercedes Maria Peck
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ruchira Maram
- Internal Medicine, Arogyasri Healthcare Trust, Hyderabad, IND
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Alaa Mohamed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, Memorial Hermann Texas Medical Center, Houston, USA
| | - Diego Ochoa Crespo
- Internal Medicine, Clinica San Martin, Azogues, ECU
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Patwari A, Bhatlapenumarthi V, Pascual SK. Atypical Posterior Reversible Encephalopathy Syndrome due to Oral Tyrosine Kinase Inhibitor Cabozantinib: First Case Report. Case Rep Oncol 2020; 13:1013-1019. [PMID: 32999665 PMCID: PMC7506375 DOI: 10.1159/000509640] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/19/2022] Open
Abstract
We report here a rare case of atypical posterior reversible encephalopathy syndrome (PRES) due to oral tyrosine kinase inhibitor cabozantinib. No case reports of such have been found in our literature search. The patient, a 70-year-old female with metastatic renal cell cancer on oral tyrosine kinase inhibitor cabozantinib, was brought into the emergency room because of confusion and seizures, found to have elevated blood pressure and atypical MRI findings consistent with PRES due to cabozantinib.
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Affiliation(s)
- Anannya Patwari
- Northern Light Eastern Maine Medical Center, Bangor, Maine, USA
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Gandini J, Manto M, Charette N. Delayed Posterior Reversible Leukoencephalopathy Syndrome Triggered by FLOT Chemotherapy. Front Neurol 2020; 10:1405. [PMID: 32082236 PMCID: PMC7002563 DOI: 10.3389/fneur.2019.01405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/23/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jordi Gandini
- Department of Neurology, CHU-Charleroi, Charleroi, Belgium
| | - Mario Manto
- Department of Neurology, CHU-Charleroi, Charleroi, Belgium
- Service des Neurosciences, University of Mons, Mons, Belgium
- *Correspondence: Mario Manto
| | - Nicolas Charette
- Department of Gastroenterology, CHU-Charleroi, Charleroi, Belgium
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