Fatal outcome of posterior “reversible” encephalopathy syndrome in metastatic colorectal carcinoma after irinotecan and fluoropyrimidine chemotherapy regimen

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic entity characterized by headaches, altered mental status, seizures, and visual disturbances. It can occur in many different clinical entities such as severe hypertension and pre-eclampsia, or due to cytotoxic or immunosuppressive therapies. The pathogenesis of PRES is unclear, with dysregulated cerebral auto-regulation and endothelial dysfunction as important mechanisms proposed. Endothelial dysfunction is important especially in cases associated with cytotoxic therapies. Herein, we describe a patient with PRES with fatal outcome, who presented 5 days after the infusion of cycle 1 of irinotecan hydrochloride, leucovorin calcium, and fluorouracil (FOLFIRI) regimen chemotherapy, without prior hypertension and other comorbidity, suggesting a link between PRES and FOLFIRI regimen. To our knowledge, this case report is the first describing PRES after FOLFIRI regimen, although others have described PRES after FOLFIRI with bevacizumab in colonic cancer patients.

An unusual presentation of a rare disease: posterior reversible encephalopathy syndrome following abdominal sepsis

“…It is hypothesized that PRES is a direct complication of endothelial injury related to a loss of cerebral autoregulation in the setting of poorly controlled hypertension. Recovery generally occurs within 5–6 days with supportive care including maintenance of normotension, treatment of sepsis and the cessation of any offending medications [1]. …”

“…Its clinical impact can be devastating and occasionally fatal [1]. Of described cases, it is estimated that greater than one third of patients will never regain baseline neurologic function [2].…”

Posterior Reversible Encephalopathy Syndrome after a Variety of Combined Chemotherapies Containing Bevacizumab for Metastatic Colon Cancer

“…The term PRES is not necessarily accurate, as brain edema is often not isolated to the posterior region ( 3 ), and the syndrome is not uniformly reversible. As discussed previously, cerebral hemorrhaging and infarction are the most common reasons for incomplete recovery, and PRES can prove fatal in severe cases ( 2 ).…”

“…In most cases, the symptoms and radiological lesions of PRES are reversible. However, the term PRES is not precisely suitable, as the syndrome is not always reversible ( 2 ) and is often not confined to either the white matter or posterior regions of the brain ( 3 ).…”

“…Certain combination regimens have been associated with PRES, including a XELOX regimen comprising oxaliplatin, capecitabine and folinic acid; a panitumumab plus FOLFIRI regimen comprising irinotecan hydrochloride, leucovorin calcium and fluorouracil; and a bevacizumab plus mFOLFOX6 regimen comprising oxaliplatin, 5-fluorouracil and L-leucovorin ( 2 , 5 - 14 ).…”