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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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2
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Do MT, Bery SK, Joyce EL, Gipsman AI. New-Onset Hypertension and Seizures in a 10-year-old Girl with Cyclic Vomiting Syndrome. Pediatr Rev 2024; 45:230-233. [PMID: 38556509 DOI: 10.1542/pir.2022-005598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Michael T Do
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Saya K Bery
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Emily L Joyce
- Division of Pediatric Nephrology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Alexander I Gipsman
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
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Thomas SJ, Ouellette CP. Viral meningoencephalitis in pediatric solid organ or hematopoietic cell transplant recipients: a diagnostic and therapeutic approach. Front Pediatr 2024; 12:1259088. [PMID: 38410764 PMCID: PMC10895047 DOI: 10.3389/fped.2024.1259088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024] Open
Abstract
Neurologic complications, both infectious and non-infectious, are frequent among hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients. Up to 46% of HCT and 50% of SOT recipients experience a neurological complication, including cerebrovascular accidents, drug toxicities, as well as infections. Defects in innate, adaptive, and humoral immune function among transplant recipients predispose to opportunistic infections, including central nervous system (CNS) disease. CNS infections remain uncommon overall amongst HCT and SOT recipients, compromising approximately 1% of total cases among adult patients. Given the relatively lower number of pediatric transplant recipients, the incidence of CNS disease amongst in this population remains unknown. Although infections comprise a small percentage of the neurological complications that occur post-transplant, the associated morbidity and mortality in an immunosuppressed state makes it imperative to promptly evaluate and aggressively treat a pediatric transplant patient with suspicion for viral meningoencephalitis. This manuscript guides the reader through a broad infectious and non-infectious diagnostic differential in a transplant recipient presenting with altered mentation and fever and thereafter, elaborates on diagnostics and management of viral meningoencephalitis. Hypothetical SOT and HCT patient cases have also been constructed to illustrate the diagnostic and management process in select viral etiologies. Given the unique risk for various opportunistic viral infections resulting in CNS disease among transplant recipients, the manuscript will provide a contemporary review of the epidemiology, risk factors, diagnosis, and management of viral meningoencephalitis in these patients.
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Affiliation(s)
- Sanya J. Thomas
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
| | - Christopher P. Ouellette
- Host Defense Program, Section of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, United States
- Division of Infectious Diseases, Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH, United States
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Jafari L, Behfar M, Tabatabaie S, Karamlou Y, Kashani H, Radmard AR, Mohseni R, Naji P, Ghanbari F, Ashkevari P, Fakhr H, Mohammadi S, Hamidieh AA. Posterior Reversible Encephalopathy Syndrome in Pediatric Hematopoietic Stem Cell Transplantation with Beta Major Thalassemia: The Association between the PRES Occurrence and Class of Beta Major Thalassemia. Clin Transplant 2024; 38:e15164. [PMID: 37847603 DOI: 10.1111/ctr.15164] [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: 08/10/2023] [Revised: 10/02/2023] [Accepted: 10/04/2023] [Indexed: 10/19/2023]
Abstract
INTRODUCTION Allogeneic hematopoietic stem cell transplantation (HSCT) is the only definitive curative option for β-major thalassemia patients (β-MT). Posterior reversible encephalopathy syndrome (PRES) is a pervasive neurological complication which typically occurs following HSCT. β-MT patients are prone to a higher PRES incidence due to long-term immunosuppression; thus, it is imperative that these patients are closely monitored for PRES after HSCT. PATIENTS AND METHODS We included 148 pediatric patients with β-MT who underwent HSCT between March 2015 and August 2022 in Children's Medical Center. Patients in this study were divided into two groups. The association between PRES and class of β-MT and other risk factors were assessed and the overall survival rate was determined. RESULTS Fourteen out of 112 patients (12%) with class I and II β-MT developed PRES. However, PRES occurred in 11 out of 36 patients (30.5%) with β-MT-III. Our results indicated that there was a significant association between class III β-MT and the occurrence of (P = .004). Additionally, acute graft-versus-host disease (aGVHD) occurred in 80% and 44.7% of patients in the PRES and non-PRES groups, respectively (P = .001). The results of the Kaplan-Meier analysis revealed that the 5-year overall survival (OS) was 75.6% in the PRES group versus 95% in the non-PRES group, which was statistically significant (P = .001). CONCLUSION Based on our results, pediatric β-MT III patients are at a higher risk of developing PRES. Additionally, pediatric β-MT patients with a history of aGVHD, regardless of disease class, are more likely to develop PRES. Considering these results, PRES has a higher chance of being the etiology of symptoms and should be considered more often in these patients.
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Affiliation(s)
- Leila Jafari
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Behfar
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Soroor Tabatabaie
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Yalda Karamlou
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Homa Kashani
- Department of Research Methodology and Data Analysis, Institute for Environmental Research, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Rashin Mohseni
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Parisa Naji
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Ghanbari
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Pooya Ashkevari
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hoda Fakhr
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shiva Mohammadi
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Ali Hamidieh
- Pediatric Cell and Gene Therapy Research Centre, Gene, Cell & Tissue Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Nada MG, Libda YI, Gohary MM, Dessouky R. Pediatric posterior reversible encephalopathy syndrome: Can MR imaging features predict outcomes in non-oncologic patients? Eur J Radiol 2024; 170:111214. [PMID: 38007856 DOI: 10.1016/j.ejrad.2023.111214] [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: 05/20/2023] [Revised: 08/09/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE Identify MR features predictive of poor outcomes in non-oncologic pediatric PRES. METHOD A six-year search of all non-oncologic pediatric patients with clinical and MR features of PRES was performed. Modified Rankin scores were used to classify clinical outcomes into good versus poor, then clinical and MR features were compared among groups. Univariate and multivariate analysis was performed to identify MR predictors of poor outcomes for various imaging features, and p-values < 0.05 were considered statistically significant. RESULTS One hundred and forty-one patients (mean age 10.1 ± 3.0 years, male to female ratio 1:1.1) were included. Clinically, nephrotic syndrome (p = 0.03), focal deficits (p = 0.04), longer hospitalization (p < 0.001), and mechanical ventilation (p < 0.001) were significantly associated with poor outcomes. Univariate analysis revealed that deep grey matter nuclei (OR = 5.29, 95 % CI: 1.6-18.0) and cerebellar edema patterns (OR = 3.49, 95 % CI: 1.3-9.5), cytotoxic edema (OR = 63.6, 95 % CI:16.5-244.2), hemorrhage (OR = 16.58, 95 % CI: 4.3-64.2), and severe PRES patterns (OR = 11.0, 95 % CI: 3.5-34.7) on MR were all significantly associated with poor outcomes (p-values = 0.008 and 0.014, <0.001, <0.001, and < 0.001, respectively). This remained true for cytotoxic edema (OR = 84.26, 95 % CI: 17.3-410.9, p-value < 0.001) and hemorrhage (OR = 44.56, 95 % CI: 6.9-289.7, p-value < 0.001) on multivariate analysis. CONCLUSION Diffusion restriction and hemorrhage on initial MR scans were the two independent predictors of poor outcomes in non-oncologic pediatric patients.
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Affiliation(s)
- Mohamad Gamal Nada
- Radiology Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Yasmin Ibrahim Libda
- Radiology Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Mahmoud M Gohary
- Pediatric Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Riham Dessouky
- Radiology Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt.
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Snyder EJ, Sarma A, Poussaint TY, Krishnasarma R, Pruthi S. Complications of Cancer Therapy in Children: A Comprehensive Review of Neuroimaging Findings. J Comput Assist Tomogr 2023; 47:820-832. [PMID: 37707414 DOI: 10.1097/rct.0000000000001481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
ABSTRACT Complications of cancer therapy in children can result in a spectrum of neurologic toxicities that may occur at the initiation of therapy or months to years after treatment. Although childhood cancer remains rare, increasing survival rates mean that more children will be living longer after cancer treatment. Therefore, complications of cancer therapy will most likely occur with increasing frequency.At times, it is very difficult to differentiate between therapeutic complications and other entities such as tumor recurrence, development of secondary malignancy, and infection (among other conditions). Radiologists often play a key role in the diagnosis and evaluation of pediatric patients with malignancies, and thus, awareness of imaging findings of cancer complications and alternative diagnoses is essential in guiding management and avoiding misdiagnosis. The aim of this review article is to illustrate the typical neuroimaging findings of cancer therapy-related toxicities, including both early and late treatment effects, highlighting pearls that may aid in making the appropriate diagnosis.
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Affiliation(s)
- Elizabeth J Snyder
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Asha Sarma
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | | | - Rekha Krishnasarma
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Sumit Pruthi
- From the Department of Radiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
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Schofield HLT, Fabrizio VA, Braniecki S, Pelletier W, Eissa H, Murphy B, Chewning J, Barton KD, Embry LM, Levine JE, Schultz KR, Page KM. Monitoring Neurocognitive Functioning After Pediatric Cellular Therapy or Hematopoietic Cell Transplant: Guidelines From the COG Neurocognition in Cellular Therapies Task Force. Transplant Cell Ther 2022; 28:625-636. [PMID: 35870778 PMCID: PMC10167710 DOI: 10.1016/j.jtct.2022.06.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/19/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023]
Affiliation(s)
| | - Vanessa A Fabrizio
- Division of Bone Marrow Transplant and Cellular Therapy, University of Colorado, Boulder, Colorado
| | - Suzanne Braniecki
- Divisions of Pediatric Psychology and Hematology/Oncology, New York Medical College, New York, New York
| | - Wendy Pelletier
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Hesham Eissa
- Division of Bone Marrow Transplant and Cellular Therapy, University of Colorado, Boulder, Colorado
| | - Beverly Murphy
- Duke Medical Center Library & Archives, Duke University, Durham, North Carolina
| | - Joseph Chewning
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Karen D Barton
- Duke Medical Center Library & Archives, Duke University, Durham, North Carolina
| | - Leanne M Embry
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - John E Levine
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kirk R Schultz
- BC Children's Hospital and Research Institute, Vancouver, British Columbia, Canada
| | - Kristin M Page
- Division of Pediatric Hematology/Oncology/BMT, Medical College of Wisconsin, Milwaukee, Wisconsin
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8
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Shash H, Aldaama S, Omer H, Alafghani S. Different Clinicoradiological Characteristics of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncology and Post-Bone Marrow Transplantation Cases: A Retrospective Study. Front Neurol 2022; 13:836033. [PMID: 35599741 PMCID: PMC9120546 DOI: 10.3389/fneur.2022.836033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is receiving increasing recognition in pediatrics. However, comparisons between PRES in pediatric oncology and post-bone marrow transplantation (BMT) are lacking. Therefore, we aimed to describe the risk factors and clinical and radiological features of PRES and investigate the differences between PRES in pediatric oncology and post-BMT. The PRES data of 13 patients from our center were combined with those of 217 cases from the PubMed, Scopus, and Web of Science databases. The patients were divided into either an oncology or a post-BMT group. We included 230 patients in the analysis, 26.1% of whom belonged to the post-BMT group. Oncology patients developed PRES at a younger age (p = 0.010) and were more likely to develop encephalopathy (p = 0.004). Systemic hypertension (S-HTN) preceding PRES occurred in 43.5% (66/154) of patients. Post-BMT patients were more likely to have S-HTN (p = 0.003). Cyclosporine levels were detected in 37 patients; 40.5% had supra-therapeutic levels. The radiological findings were atypical in 74.3% of patients, and delayed repeated imaging increased the occurrence of resolution (p = 0.004). Sixteen (7%) patients developed PRES recurrence after a median of 8 weeks, with the between-group difference being non-significant. Oncology patients were more likely to develop chronic epilepsy, while BMT patients were more likely to develop rare neurologic abnormalities (p < 0.001). In conclusion, atypical clinical presentation and imaging findings should not hinder the diagnosis of PRES. S-HTN is a risk factor, particularly in post-BMT patients. Supra-therapeutic levels of cyclosporine and previous exposure to immunosuppression did not increase the risk of recurrence.
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Affiliation(s)
- Hwazen Shash
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Department of Pediatrics, King Fahad Hospital of the University, Al-Khobar, Saudi Arabia
- *Correspondence: Hwazen Shash ; orcid.org/0000-0002-4128-9504
| | - Saad Aldaama
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Hala Omer
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Sameera Alafghani
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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Leung KKY, Hon KL, Hui WF, Leung AK, Li CK. Therapeutics for paediatric oncological emergencies. Drugs Context 2021; 10:dic-2020-11-5. [PMID: 34234831 PMCID: PMC8232653 DOI: 10.7573/dic.2020-11-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/20/2021] [Indexed: 12/19/2022] Open
Abstract
Background With advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies. Methods An extensive PubMed® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years. Results The general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life. Conclusions Oncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.
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Affiliation(s)
- Karen Ka Yan Leung
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Kam Lun Hon
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Wun Fung Hui
- Paediatric Intensive Care Unit, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| | - Alexander Kc Leung
- Department of Pediatrics, The University of Calgary and The Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Chi Kong Li
- Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong.,Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
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10
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Posterior Reversible Encephalopathy Syndrome in Childhood Hematological/Oncological Diseases: Multicenter Results. J Pediatr Hematol Oncol 2021; 43:e462-e465. [PMID: 33060391 DOI: 10.1097/mph.0000000000001965] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/10/2020] [Indexed: 11/27/2022]
Abstract
The aim of the study was to analyze the characteristics of posterior reversible encephalopathy syndrome (PRES) cases treated at 10 different institutions in our country. Fifty-eight patients diagnosed with PRES were included in this study. The data of PRES cases from 10 departments of pediatric hematology/oncology were analyzed. The mean age of the patients at the time of diagnosis of PRES was 8.95±3.66 years. Most patients (80.4%) had a primary diagnosis of acute leukemia. Patients received chemotherapy (71.4%) and/or used steroids within 14 days before the diagnosis of PRES (85.7%). Hypertension was found in 83.9% of the patients. Twenty-six patients had infections and 22 of them had febrile neutropenia. The most common electrolyte disorders were hypocalcemia, hypomagnesemia, and hypopotassemia. Six patients had tumor lysis syndrome and 4 had inappropriate antidiuretic hormone syndrome. Magnetic resonance imaging was used for diagnosis in all patients. The most commonly involved regions by magnetic resonance imaging were occipital (58%), parietal (51%), and frontal lobes (45%), respectively. Twenty-five patients required intensive care and 7 patients were intubated. In conclusion, PRES may develop during the follow-up and treatment of hematological diseases. In addition to steroid and intense combined chemotherapies, immunosuppressive agents and hypertension are also factors that may be responsible for PRES.
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11
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Wang Y, Zheng Y, Wen J, Ren J, Yuan X, Yang T, Hu J. Cyclosporine A-related neurotoxicity after haploidentical hematopoietic stem cell transplantation in children with hematopathy. Ital J Pediatr 2021; 47:83. [PMID: 33794964 PMCID: PMC8017700 DOI: 10.1186/s13052-021-01037-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/23/2021] [Indexed: 12/02/2022] Open
Abstract
Background To evaluate cyclosporine A (CSA)-related neurotoxicity after haploidentical hematopoietic stem cell transplantation (HID-HSCT) in children with hematopathy. Methods This retrospective case series study included children with hematopathy who underwent HID-HSCT at Fujian Medical University Union Hospital between February 2013 and January 2017. Results Fifty-one children (39 males) were included in the study with a median age of 8 (range, 1.1–18) years. Seven patients (13.7%) developed CSA-related neurotoxicity after a median 38 (range, − 3 to 161) days from HID-HSCT. Hypertension (5/7, 71%) was the most common prodrome. Brain magnetic resonance imaging showed posterior reversible encephalopathy syndrome in six patients and atypical abnormalities in one patient. One patient died from grade IV graft-versus-host disease (GvHD) on day + 160, and six patients were alive at the last follow-up. Four patients (71.4%) achieved complete remission, while two patients developed secondary epilepsy and exhibited persistent MRI and electroencephalogram abnormalities at the 5-year follow-up. Hypertension after CSA was more common in patients with CSA-related neurotoxicity than in those without (71% vs. 11%, P = 0.002). Five-year overall survival did not differ significantly between patients with CSA-related neurotoxicity (85.7 ± 13.2%) and those without (65.8 ± 7.2%). Conclusions The incidence of CSA-related neurotoxicity in children with hematopathy undergoing HID-HSCT is relatively high.
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Affiliation(s)
- Yong Wang
- Department of Pediatric, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Yongzhi Zheng
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Jingjing Wen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Jinhua Ren
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Xiaohong Yuan
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China
| | - Ting Yang
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China.
| | - Jianda Hu
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Gulou District, Fuzhou City, Fujian Province, China.
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12
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Ricci E, Toni F, Marra C, Masetti R, Porelli S, Balducci J, Pession A, Cordelli DM. Computed Tomography in Acute Severe Central Nervous System Complications in Children Treated for Cancer: Still a Useful Diagnostic Tool in the Emergency Setting. J Child Neurol 2021; 36:169-176. [PMID: 33076756 DOI: 10.1177/0883073820962354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We retrospectively checked patients who underwent chemotherapy and/or hematopoietic stem cell transplantation from 2007 to 2016, in order to evaluate whether early computed tomography is useful in children treated for cancer with acute central nervous system complications. Out of a total sample of 443 patients, 52 children (11.7%) presented these complications. In the end, 31 patients were included, with a total of 33 events of central nervous system complications. The computed tomography was abnormal in 22 events (67%) and diagnostic for a specific complication in 20 events (61%), whereas it directly influenced the treatment in 16 events (48%). Computed tomography should be still considered a relevant diagnostic tool in the management of acute central nervous system complications in the emergency setting.
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Affiliation(s)
- Emilia Ricci
- Child Neurology and Psychiatry Unit, 18508University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy.,Child Neuropsychiatry Unit, Epilepsy Center, San Paolo Hospital, Milan, Italy
| | - Francesco Toni
- 419170IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuroradiologia, Bologna, Italia
| | - Chiara Marra
- Child Neurology and Psychiatry Unit, 18508University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Riccardo Masetti
- Department of Pediatrics, "Lalla Seràgnoli" Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Sayuri Porelli
- 419170IRCCS Istituto delle Scienze Neurologiche di Bologna, UOC Neuroradiologia, Bologna, Italia
| | - Jessica Balducci
- Psychiatry Unit, Department of Biomedical, Metabolic and Neural Sciences, 9306University of Modena and Reggio Emilia, Modena, Italy
| | - Andrea Pession
- Department of Pediatrics, "Lalla Seràgnoli" Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Duccio Maria Cordelli
- Child Neurology and Psychiatry Unit, 18508University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy
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13
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Hun M, Xie M, She Z, Abdirahman AS, Li C, Wu F, Luo S, Han P, Phorn R, Wu P, Luo H, Chen K, Tian J, Wan W, Wen C. Management and Clinical Outcome of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncologic/Hematologic Diseases: A PRES Subgroup Analysis With a Large Sample Size. Front Pediatr 2021; 9:678890. [PMID: 34277519 PMCID: PMC8280768 DOI: 10.3389/fped.2021.678890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/02/2021] [Indexed: 12/13/2022] Open
Abstract
This study investigated the management and clinical outcomes along with associated factors of posterior reversible encephalopathy syndrome (PRES) in childhood hematologic/oncologic diseases. We present data from children with hematologic/oncologic diseases who developed PRES after treatment of the primary disease with chemotherapy and hematopoietic stem cell transplantation (HSCT) at 3 medical centers in Changsha, China from 2015 to 2020, and review all previously reported cases with the aim of determining whether this neurologic manifestation affects the disease prognosis. In the clinical cohort of 58 PRES patients, hypertension [pooled odds ratio (OR) = 4.941, 95% confidence interval (CI): 1.390, 17.570; P = 0.001] and blood transfusion (OR = 14.259, 95% CI: 3.273, 62.131; P = 0.001) were significantly associated with PRES. Elevated platelet (OR = 0.988, 95% CI: 0.982, 0.995; P < 0.001), hemoglobin (OR = 0.924, 95% CI: 0.890, 0.995; P < 0.001), and blood sodium (OR = 0.905, 95% CI: 0.860, 0.953; P < 0.001), potassium (OR = 0.599, 95% CI: 0.360, 0.995; P = 0.048), and magnesium (OR = 0.093, 95% CI: 0.016, 0.539; P = 0.008) were protective factors against PRES. Data for 440 pediatric PRES patients with hematologic/oncologic diseases in 21 articles retrieved from PubMed, Web of Science, and Embase databases and the 20 PRES patients from our study were analyzed. The median age at presentation was 7.9 years. The most common primary diagnosis was leukemia (62.3%), followed by solid tumor (7.7%) and lymphoma (7.5%). Most patients (65.0%) received chemotherapy, including non-induction (55.2%) and induction (44.8%) regimens; and 86.5% used corticosteroids before the onset of PRES. Although 21.0% of patients died during follow-up, in most cases (93.2%) this was not attributable to PRES but to severe infection (27.3%), underlying disease (26.1%), graft-vs.-host disease (14.8%), multiple organ dysfunction syndrome (8.0%), and respiratory failure (3.4%). PRES was more common with HSCT compared to chemotherapy and had a nearly 2 times higher mortality rate in patients with oncologic/hematologic diseases than in those with other types of disease. Monitoring neurologic signs and symptoms in the former group is therefore critical for ensuring good clinical outcomes following treatment of the primary malignancy.
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Affiliation(s)
- Marady Hun
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Min Xie
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhou She
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Amin S Abdirahman
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Cuifang Li
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Feifeng Wu
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Senlin Luo
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Phanna Han
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Rithea Phorn
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Pan Wu
- Department of Hematology, Hunan Children's Hospital, University of South China, Changsha, China
| | - Haiyan Luo
- Department of Hematology, Hunan Children's Hospital, University of South China, Changsha, China
| | - Keke Chen
- Department of Hematology, Children's Medical Center, Hunan Provincial People's Hospital, Hunan Normal University, Changsha, China
| | - Jidong Tian
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wuqing Wan
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chuan Wen
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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14
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Gabriel M, Hoeben BAW, Uhlving HH, Zajac-Spychala O, Lawitschka A, Bresters D, Ifversen M. A Review of Acute and Long-Term Neurological Complications Following Haematopoietic Stem Cell Transplant for Paediatric Acute Lymphoblastic Leukaemia. Front Pediatr 2021; 9:774853. [PMID: 35004543 PMCID: PMC8734594 DOI: 10.3389/fped.2021.774853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/02/2021] [Indexed: 12/02/2022] Open
Abstract
Despite advances in haematopoietic stem cell transplant (HSCT) techniques, the risk of serious side effects and complications still exists. Neurological complications, both acute and long term, are common following HSCT and contribute to significant morbidity and mortality. The aetiology of neurotoxicity includes infections and a wide variety of non-infectious causes such as drug toxicities, metabolic abnormalities, irradiation, vascular and immunologic events and the leukaemia itself. The majority of the literature on this subject is focussed on adults. The impact of the combination of neurotoxic drugs given before and during HSCT, radiotherapy and neurological complications on the developing and vulnerable paediatric and adolescent brain remains unclear. Moreover, the age-related sensitivity of the nervous system to toxic insults is still being investigated. In this article, we review current evidence regarding neurotoxicity following HSCT for acute lymphoblastic leukaemia in childhood. We focus on acute and long-term impacts. Understanding the aetiology and long-term sequelae of neurological complications in children is particularly important in the current era of immunotherapy for acute lymphoblastic leukaemia (such as chimeric antigen receptor T cells and bi-specific T-cell engager antibodies), which have well-known and common neurological side effects and may represent a future treatment modality for at least a fraction of HSCT-recipients.
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Affiliation(s)
- Melissa Gabriel
- Cancer Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Hilde Hylland Uhlving
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Olga Zajac-Spychala
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznań, Poland
| | - Anita Lawitschka
- Haematopoietic Stem Cell Transplant Unit, St. Anna Children's Hospital, Medical University Vienna, Vienna, Austria
| | - Dorine Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Marianne Ifversen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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15
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Hafez HA, Ragab I, Sedky M, Shams M, Youssef A, Refaat A, Habib E, Sidhom I. Patterns, risk factors and outcome predictors of posterior reversible encephalopathy syndrome in pediatric cancer patients. Leuk Lymphoma 2020; 62:462-468. [PMID: 33063564 DOI: 10.1080/10428194.2020.1832658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The purpose of this study was to assess the clinical and radiological patterns and outcome predictors of posterior reversible encephalopathy syndrome (PRES) in pediatric cancer patients. A retrospective study included patients who developed PRES during their treatment at the Children's Cancer Hospital Egypt. A total of 50 patients developed PRES. Leukemia and lymphoma were the commonest diagnoses (64%). Regarding the MRI findings, occipital affection was the most common (92%), followed by frontal and temporal lobes involvement in 32% and 22% respectively and advanced PRES was described in 8 patients. Of the whole patients, 80% had complete clinical resolution and 60% showed complete radiological resolution at 2 weeks' evaluation and 2 patients died out of PRES. Unfavorable outcome was associated with those who had motor dysfunction, status epilepticus at presentation, frontal lobe and thalamic affection and atypical PRES. PRES might present in atypical sites with poor outcome including death.
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Affiliation(s)
- Hanafy A Hafez
- Department of Pediatric Oncology, National Cancer institute, Cairo University, Cairo, Egypt.,Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Iman Ragab
- Pediatric Department, Hematology-Oncology Unit, Ain Shams University, Cairo, Egypt
| | - Mohamed Sedky
- Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Marwa Shams
- Pediatric Department, Hematology-Oncology Unit, Ain Shams University, Cairo, Egypt
| | - Ayda Youssef
- Radiology Department, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Amal Refaat
- Radiology Department, Children's Cancer Hospital Egypt, Cairo, Egypt
| | - Elsaeed Habib
- Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt.,Pediatric Department, Hematology-Oncology Unit, Ain Shams University, Cairo, Egypt
| | - Iman Sidhom
- Department of Pediatric Oncology, National Cancer institute, Cairo University, Cairo, Egypt.,Department of Pediatric Oncology, Children's Cancer Hospital Egypt, Cairo, Egypt
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16
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Peak blood pressure and prediction of posterior reversible encephalopathy syndrome in children. Pediatr Nephrol 2020; 35:1967-1975. [PMID: 32385528 PMCID: PMC8086820 DOI: 10.1007/s00467-020-04577-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 04/06/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hypertension is a risk factor for posterior reversible encephalopathy syndrome (PRES), but the timing and severity of hypertension relative to PRES are unknown. The objective was to identify a clinically meaningful blood pressure (BP) threshold that predicts PRES development in high-risk children. METHODS We recorded peak systolic BP, diastolic BP, BP z-scores, and mean arterial pressure over the 14 days preceding clinical concern for PRES in 35 subjects who developed PRES, compared to 14 controls who had normal brain magnetic resonance imaging and similar underlying disease, renal function, and medications. We used multivariable logistic regression models adjusted for fluid overload and obesity to estimate the association of peak BP with PRES. We used receiver operating characteristic curves to determine which peak BP thresholds best predicted PRES and calculated the corresponding sensitivity, specificity, and positive and negative predictive values. RESULTS Peak systolic BP z-score was most strongly associated with PRES (OR 3.97, 95% CI 1.62-9.74), and peak systolic BP z-score ≥ 3.0 predicted PRES (area under the curve 0.95, 95% CI 0.88-1.0) with 91% sensitivity and 85% specificity, indicating 94% positive predictive value and 79% negative predictive value. CONCLUSIONS We demonstrated that peak systolic BP z-score ≥ 3.0 in the preceding 14 days predicted PRES development in cases compared with controls in children at high risk. Our study suggests that stage 2 hypertension, corresponding to a z-score ≥ 3.0, could help define hypertensive emergency in high-risk children and indicate when more aggressive treatment is warranted to prevent neurologic injury.
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17
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Hun M, Tian J, Xie M, She Z, Abdirahman AS, Han P, Wan W, Wen C. Analysis of Risk Factors Associated With Poor Outcome in Posterior Reversible Encephalopathy Syndrome After Treatment in Children: Systematic Review and Meta-Analysis. Front Neurol 2020; 11:938. [PMID: 32982945 PMCID: PMC7479335 DOI: 10.3389/fneur.2020.00938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/20/2020] [Indexed: 12/15/2022] Open
Abstract
Objective: Chemotherapy and hematopoietic stem cell transplantation (HSCT) play important roles in clinical etiology, symptoms, signs, imaging findings, and biochemical parameters for inducing posterior reversible encephalopathy syndrome (PRES) in pediatric oncologic diseases. We aimed to evaluate various risk factors of pediatric oncologic diseases after conducting chemotherapy and HSCT to induce PRES for predicting the clinical prognosis frequency. Methods: The literature was performed on PubMed, Web of Science, and Embase databases to recognize the qualified studies. The odds ratios (ORs) of related risk factors and their corresponding 95% confidence intervals (CIs) were used to compute the pooled assessments of the outcomes. Results: Six studies were included in the meta-analysis, involving 828 records. The risk of female children has a significantly higher incidence than male children in oncologic age groups of PRES. Children over the age of 10 years old in oncologic age groups develop a significantly increased risk of PRES. Acute graft-versus-host disease (GVHD) has a significant promotion effect on the occurrence of PRES. Hypertension can promote the occurrence of PRES in children. The risk of PRES in immunodeficient children increases significantly. Children with sickle cell disease (SCD) have a significantly increased risk of PRES. The risk of PRES in children with T-cell leukemia rises considerably. The central nervous system (CNS) leukemia/involvement has a significant role in promoting the occurrence of PRES in children. The pooled OR for the factors male, ≥ 10 years old of age, acute GVHD, hypertension, immunodeficiency, SCD, T-cell leukemia, CNS leukemia/involvement was 0.66 (95% CI: 0.58, 0.76; P < 0.00001), 2.06 (95% CI: 1.23, 3.43; P < 0.006), 1.32 (95% CI: 1.14, 1.53; P < 0.0003), 8.84 (95% CI: 7.57, 10.32; P < 0.00001), 2.72 (95% CI: 1.81, 4.08; P < 0.00001), 2.87 (95% CI: 2.15, 3.83; P < 0.00001), 2.84 (95% CI: 1.65, 4.88; P < 0.0002), and 3.13 (95% CI: 1.43, 6.84; P < 0.004), respectively. Conclusions: The result of this meta-analysis suggests that female children, age over 10 years old, acute GVHD, hypertension, immunodeficiency, SCD, T-cell leukemia, and CNS leukemia/involvement are likely to have the poor outcome in pediatric oncologic/hematologic diseases in PRES.
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Affiliation(s)
- Marady Hun
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jidong Tian
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Min Xie
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Zhou She
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Amin Sheikh Abdirahman
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Phanna Han
- Department of Ophthalmology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Wuqing Wan
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chuan Wen
- Division of Hematology and Tumor, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
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18
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Anderson RC, Patel V, Sheikh-Bahaei N, Liu CSJ, Rajamohan AG, Shiroishi MS, Kim PE, Go JL, Lerner A, Acharya J. Posterior Reversible Encephalopathy Syndrome (PRES): Pathophysiology and Neuro-Imaging. Front Neurol 2020; 11:463. [PMID: 32612567 PMCID: PMC7308488 DOI: 10.3389/fneur.2020.00463] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 04/29/2020] [Indexed: 12/18/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) represents a unique clinical entity with non-specific clinical symptoms and unique neuroradiological findings. This syndrome may present with a broad range of clinical symptoms from headache and visual disturbances to seizure and altered mentation. Typical imaging findings include posterior-circulation predominant vasogenic edema. Although there are many well-documented diseases associated with PRES, the exact pathophysiologic mechanism has yet to be fully elucidated. Generally accepted theories revolve around disruption of the blood-brain barrier secondary to elevated intracranial pressures or endothelial injury. In this article, we will review the clinical, typical, and atypical radiological features of PRES, as well as the most common theories behind the pathophysiology of PRES. Additionally, we will discuss some of the treatment strategies for PRES related to the underlying disease state.
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Affiliation(s)
- Redmond-Craig Anderson
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Vishal Patel
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Nasim Sheikh-Bahaei
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Chia Shang J Liu
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Anandh G Rajamohan
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Mark S Shiroishi
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Paul E Kim
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - John L Go
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Alexander Lerner
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Jay Acharya
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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19
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Chen Q, Zhao X, Fu HX, Chen YH, Zhang YY, Wang JZ, Wang Y, Wang FR, Mo XD, Han W, Chen H, Chang YJ, Xu LP, Liu KY, Huang XJ, Zhang XH. Posterior reversible encephalopathy syndrome (PRES) after haploidentical haematopoietic stem cell transplantation: incidence, risk factors and outcomes. Bone Marrow Transplant 2020; 55:2035-2042. [PMID: 32305999 DOI: 10.1038/s41409-020-0894-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 03/29/2020] [Accepted: 03/30/2020] [Indexed: 01/09/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a gradually recognised neurological complication of allogenic haematopoietic stem cell transplantation (allo-HSCT). However, there is a paucity of information on PRES after haploidentical HSCT (haplo-HSCT). We performed a retrospective nested case-control study in patients following haplo-HSCT for malignant and nonmalignant haematologic diseases between January 2009 and December 2018 in our centre. A total of 45 patients were diagnosed with PRES after transplant, accounting for an incidence of 1.17%. Grades II to IV acute graft-versus-host disease (aGVHD) (HR 2.370, 95% CI 1.277-4.397, p = 0.006) and hypertension (HR 14.466, 95% CI 7.107-29.443, p < 0.001) were identified as risk factors for developing PRES after haplo-HSCT. There was no difference in overall survival (OS), disease-free survival (DFS), the cumulative incidence of relapse or nonrelapse mortality (NRM) between patients with PRES and controls without PRES following haplo-HSCT in either adults or children. All but one patient with PRES showed nearly complete clinical and neurologic recovery. In conclusion, PRES is a rare condition with benign outcomes following haplo-HSCT. Further multicentre prospective studies are needed to confirm the results and help to establish the standard therapy for posttransplant PRES.
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Affiliation(s)
- Qi Chen
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xin Zhao
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Beijing, China.,Peking University Institute of Hematology, Beijing, China.,National Clinical Research Center for Hematologic Disease, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Beijing, China. .,Peking University Institute of Hematology, Beijing, China. .,National Clinical Research Center for Hematologic Disease, Beijing, China. .,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.
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20
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Ghali MGZ, Styler MJ. Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1702934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractThe posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.
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Affiliation(s)
- Michael G. Z. Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Michael J. Styler
- Department of Hematology and Oncology, Hahnemann University Hospital, Philadelphia, Pennsylvania, United States
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21
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Banerjee J, Niinimäki R, Lähteenmäki P, Hed Myrberg I, Arola M, Riikonen P, Lönnqvist T, Palomäki M, Ranta S, Harila-Saari A, Taskinen M. The spectrum of acute central nervous system symptoms during the treatment of childhood acute lymphoblastic leukaemia. Pediatr Blood Cancer 2020; 67:e27999. [PMID: 31674724 DOI: 10.1002/pbc.27999] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/06/2019] [Accepted: 08/23/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Children with central nervous system (CNS) toxicity during therapy for acute lymphoblastic leukaemia (ALL) are at risk for treatment modifications, long-term sequelae and even higher mortality. A better understanding of CNS symptoms and their complications improves the potential to prevent and treat them. METHODS Patient files from 649 children treated with Nordic Society of Pediatric Hematology and Oncology ALL92 and ALL2000 protocols in Finland were reviewed retrospectively for any acute CNS symptom. Detailed data on symptoms, examinations and treatment of the underlying CNS complications were collected from the medical records. Disease-related and outcome data were retrieved from the Nordic leukaemia registry. RESULTS Altogether, 13% (86) of patients with ALL had acute CNS symptoms. Most symptoms (64%) occurred during the first 2 months of therapy. Posterior reversible encephalopathy syndrome was the most frequent complication (4.5%). Cerebrovascular events were diagnosed in 10 cases (1.6%), while methotrexate-related stroke-like syndrome (SLS) was observed in only one patient (0.2%). CNS symptoms due to systemic or unclear conditions, especially sepsis, were important for differential diagnosis. CNS leukaemia was associated with CNS symptoms (hazard ratio [HR] = 4.03; P = .003), and epilepsy was a common sequel of CNS complications (19%). CONCLUSIONS Acute CNS symptoms are common during ALL therapy, occurring mainly during the first 2 months of treatment. Patients with CNS leukaemia at diagnosis are at a higher risk for CNS toxicity. Despite intensive CNS-directed methotrexate treatment, SLS was diagnosed extremely rarely in our series.
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Affiliation(s)
- Joanna Banerjee
- Division of Pediatric Hematology and Oncology and Stem Cell Transplantation, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Riitta Niinimäki
- Department of Children and Adolescents, Oulu University Hospital and PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Päivi Lähteenmäki
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital and Turku University, Turku, Finland
| | - Ida Hed Myrberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Mikko Arola
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland.,Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Pekka Riikonen
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Tuula Lönnqvist
- Division of Child Neurology, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Maarit Palomäki
- Department of Radiology, Helsinki Medical Imaging Center, Helsinki University Hospital, Helsinki, Finland
| | - Susanna Ranta
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Mervi Taskinen
- Division of Pediatric Hematology and Oncology and Stem Cell Transplantation, Helsinki University Hospital and Helsinki University, Helsinki, Finland
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22
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Abstract
AIM To evaluate clinical and radiologic presentation, and neurologic outcome of pediatric posterior reversible encephalopathy syndrome (PRES). PATIENTS AND METHODS The study included 24 children (14 males and 10 females) diagnosed with PRES who were prospectively followed for 2 years. They were evaluated using Wechsler Intelligence Scale, electroencephalograph (EEG), and brain magnetic resonance imaging (MRI). RESULTS The mean age of the studied patients at the time of diagnosis of PRES was 6 years (±2.2). Chemotherapy for cancer represented 66.7% of the causes of PRES in the studied children, followed by renal disorders and immunosuppressive agents for hematopoietic stem cell transplantation. Twenty-seven attacks of PRES were reported as 3 children developed a second attack of PRES. Normal intelligence quotient was found in 95.8% of studied children after PRES. Residual abnormalities in follow-up MRI were demonstrated in 3 children. Epilepsy and residual MRI lesions were reported in 2 of the 3 children with recurrent PRES. Residual lesions in follow-up MRI and epilepsy were more significantly reported after recurrent PRES (P < .05). CONCLUSIONS Neoplastic, renal disorders and hematopoietic stem cell transplantation represent the main disorders associated with PRES in children. Chemotherapeutic drugs, immunosuppressants, and hypertension are the main risk factors for pediatric PRES. The outcome of pediatric PRES is good, but long-term neurologic sequelae can occur, mainly epilepsy and residual MRI abnormalities. Recurrence of PRES is infrequently reported in children receiving chemotherapeutic or immunosuppressive drugs. Recurrent PRES is a risk factor for long-term neurologic sequelae.
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Affiliation(s)
- Amira Hamed Darwish
- Pediatric Neurology Unit, Department of Pediatrics, Faculty of Medicine, Tanta University Hospital, Egypt
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23
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Anastasopoulou S, Eriksson MA, Heyman M, Wang C, Niinimäki R, Mikkel S, Vaitkevičienė GE, Johannsdottir IM, Myrberg IH, Jonsson OG, Als-Nielsen B, Schmiegelow K, Banerjee J, Harila-Saari A, Ranta S. Posterior reversible encephalopathy syndrome in children with acute lymphoblastic leukemia: Clinical characteristics, risk factors, course, and outcome of disease. Pediatr Blood Cancer 2019; 66:e27594. [PMID: 30592147 DOI: 10.1002/pbc.27594] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/04/2018] [Accepted: 12/07/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a distinct entity with incompletely known predisposing factors. The aim of this study is to describe the incidence, risk factors, clinical course, and outcome of PRES in childhood acute lymphoblastic leukemia (ALL). PROCEDURE Patients aged 1.0 to 17.9 years diagnosed with ALL from July 2008 to December 2015 and treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol were included. Patients with PRES were identified in the prospective NOPHO leukemia toxicity registry, and clinical data were collected from the medical records. RESULTS The study group included 1378 patients, of whom 52 met the criteria for PRES. The cumulative incidence of PRES at one month was 1.7% (95% CI, 1.1-2.5) and at one year 3.7% (95% CI, 2.9-4.9). Older age (hazard ratios [HR] for each one-year increase in age 1.1; 95% CI, 1.0-1.2, P = 0.001) and T-cell immunophenotype (HR, 2.9; 95% CI, 1.6-5.3, P = 0.0005) were associated with PRES. Central nervous system (CNS) involvement (odds ratios [OR] = 2.8; 95% CI, 1.2-6.5, P = 0.015) was associated with early PRES and high-risk block treatment (HR = 2.63; 95% CI, 1.1-6.4, P = 0.033) with late PRES. At follow-up of the PRES patients, seven patients had epilepsy and seven had neurocognitive difficulties. CONCLUSION PRES is a neurotoxicity in the treatment of childhood ALL with both acute and long-term morbidity. Older age, T-cell leukemia, CNS involvement and high-risk block treatment are risk factors for PRES.
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Affiliation(s)
- Stavroula Anastasopoulou
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Mats A Eriksson
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Chen Wang
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Riitta Niinimäki
- Oulu University Hospital, Department of Children and Adolescents, and University of Oulu, PEDEGO Research Unit, Oulu, Finland
| | - Sirje Mikkel
- Department of Hematology and Oncology, University of Tartu, Tartu, Estonia
| | - Goda E Vaitkevičienė
- Children's Hospital, affiliation of Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | | | - Ida Hed Myrberg
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | | | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, and Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, and Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Joanna Banerjee
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arja Harila-Saari
- Department of Women's and Children's Health, University of Uppsala, Uppsala, Sweden
| | - Susanna Ranta
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
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24
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Zou LP, Liu LY, Li H, Wang YY, Liu Y, Chen J, Hu LY, Liu MJ, Zhang MN, Lu Q, Ma SF. Establishment and utility assessment of posterior reversible encephalopathy syndrome early warning scoring (PEWS) scale establishment and utility assessment of PEWS scale. BMC Neurol 2019; 19:30. [PMID: 30791893 PMCID: PMC6385440 DOI: 10.1186/s12883-019-1247-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 01/30/2019] [Indexed: 11/21/2022] Open
Abstract
Background Posterior reversible encephalopathy syndrome (PRES) is a complication that occurs during various diseases’ treatment. Imaging examination is the gold standard for diagnosis. PRES frequently occurrence in patients with hematological malignancies results in poorer prognosis and higher mortality. We aim to establish a practical and operable scale for early prediction, assessment of the severity of the Posterior Reversible Encephalopathy Syndrome, and timely intervention for better prognosis. Methods The scale designed by reviewing the literature and by referring to clinical practice. We assessed the reliability and validity of the scale. Scale-based assessment of children undergoing chemotherapy for acute lymphoblastic leukemia conducted as early warning and intervention for those who may have PRES. Results Establishment of Posterior Reversible Encephalopathy Syndrome early warning scoring (PEWS) scale included three parts, as follows: (1) risk factors, including underlying disease, hypertension, Infection, and drug toxicity; (2) clinical features, including high cranial pressure, visual symptoms, seizure, and disturbance of consciousness; and (3) EEG features, including slow wave and epileptiform discharges. Utility assessment of PEWS scale showed that in 57 patients with acute lymphoblastic leukemia, 54 scored less than 10 and none of them detected as PRES. The other two had scores of 12 and 13 both diagnosed with PRES by brain MRI scan. Conclusions PEWS scale can predict PRES early. PRES was highly suspected when the score was 10 points and more. Thus, prophylactic intervention can give to improve the prognosis of PRES.
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Affiliation(s)
- Li-Ping Zou
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China. .,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, 100069, China.
| | - Li-Ying Liu
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Hui Li
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Yang-Yang Wang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Ying Liu
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Jing Chen
- Key Laboratory of Pediatric Hematology & Oncology, Ministry of Health, Department of Hematology and Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Lin-Yan Hu
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Meng-Jia Liu
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Meng-Na Zhang
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Qian Lu
- Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, 100069, China
| | - Shu-Fang Ma
- Department of Pediatrics, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
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25
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Sun LR, Cooper S. Neurological Complications of the Treatment of Pediatric Neoplastic Disorders. Pediatr Neurol 2018; 85:33-42. [PMID: 30126755 DOI: 10.1016/j.pediatrneurol.2018.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/25/2018] [Indexed: 01/19/2023]
Abstract
Neurological complications resulting from childhood cancer treatments are common. Treatment for childhood neoplastic disorders is often multimodal and may include procedures, cranial irradiation, chemotherapy, transplant, and immunotherapy, each of which carries distinct neurological risks. Procedures, such as lumbar punctures, are commonly used in this population for diagnostic purposes as well as intrathecal medication administration. Surgery is associated with an array of potential neurological complications, with posterior fossa syndrome being a common cause of morbidity in pediatric brain tumor patients after neurosurgical resection. Cranial irradiation can cause late neurological sequelae such as stroke, cerebral vasculopathy, secondary malignancy, and cognitive dysfunction. Neurotoxic effects of chemotherapeutic agents are common and include neuropathy, coagulopathy causing stroke or cerebral sinovenous thrombosis, encephalopathy, seizures, cerebellar dysfunction, myelopathy, and neuropsychologic difficulties. Hematopoietic stem cell transplant has a high risk of neurological complications including central nervous system infection, seizures, and stroke. Immunotherapies, including chimeric antigen receptor-modified T-cells (CAR T-cells) and immune checkpoint inhibitors, are emerging as potentially effective strategies to treat some types of childhood cancer, but may carry with them substantial neurotoxicity which is just beginning to be recognized and studied. With evolving treatment protocols, childhood cancer survivorship is increasing, and the role of the neurologist in managing both the acute and chronic neurological consequences of treatment is becoming more important. Prevention, early recognition, and treatment of therapy-associated neurotoxicity are imperative to ensuring children can remain on the most effective therapeutic regimens and to improve the neurological function and quality of life of childhood cancer survivors.
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Affiliation(s)
- Lisa R Sun
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Pediatric Neurology, Baltimore, Maryland; The Johns Hopkins University School of Medicine, Department of Neurology, Division of Cerebrovascular Neurology, Baltimore, Maryland.
| | - Stacy Cooper
- The Johns Hopkins University School of Medicine, Department of Oncology, Division of Pediatric Oncology, Baltimore, Maryland
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26
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Dulamea AO, Lupescu IG. Neurological complications of hematopoietic cell transplantation in children and adults. Neural Regen Res 2018; 13:945-954. [PMID: 29926815 PMCID: PMC6022482 DOI: 10.4103/1673-5374.233431] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Hematopoietic cell transplantation (HCT) is widely performed for neoplastic and non-neoplastic diseases. HCT involves intravenous infusion of hematopoietic progenitor cells from human leukocyte antigen (HLA)-matched donor (allogeneic) or from the patient (autologous). Before HCT, the patient is prepared with high dose chemotherapy and/or radiotherapy to destroy residual malignant cells and to reduce immunologic resistance. After HCT, chemotherapy is used to prevent graft rejection and graft versus host disease (GvHD). Neurological complications are related to the type of HCT, underlying disease, toxicity of the conditioning regimens, immunosuppression caused by conditioning regimens, vascular complications generated by thrombocytopenia and/or coagulopathy, GvHD and inappropriate immune response. In this review, neurological complications are presented according to time of onset after HCT: (1) early complications (in the first month) - related to harvesting of stem cells, during conditioning (drug toxicity, posterior reversible encephalopathy syndrome), related to pancytopenia, (2) intermediate phase complications (second to sixth month) - central nervous system infections caused by prolonged neutropenia and progressive multifocal leukoencephalopathy due to JC virus, (3) late phase complications (after sixth month) - neurological complications of GvHD, second neoplasms and relapses of the original disease.
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Affiliation(s)
- Adriana Octaviana Dulamea
- University of Medicine and Pharmacy Carol Davila; Department of Neurology, Fundeni Clinical Institute, Bucharest, Romania
| | - Ioana Gabriela Lupescu
- University of Medicine and Pharmacy Carol Davila; Radiology and Medical Imaging Department, Fundeni Clinical Institute, Bucharest, Romania
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