Posterior reversible encephalopathy manifested by refractory status epilepticus in two patients under chemotherapy

Abstract

DESCRIPTIONPosterior reversible encephalopathy (PRES) is a clinicalradiological syndrome characterised by brain symmetric lesions of vasogenic oedema, in white matter, basal ganglia or cerebral cortex, preferentially in posterior topography. 1 Typical manifestations are headache and altered mental status. Epileptic seizures are also frequent, although status epilepticus (SE) is a rare occurrence. 2 Chemotherapy may trigger PRES. Nevertheless, no single chemotherapy agent was consistently implicated. 2 Two cases are presented: a young man (patient 1) with a Hodgkin lymphoma, under ABVD chemotherapy (adriamicin, vinblastine, bleomicine, dacarbazin), and an adult woman (patient 2), under docetaxel and gemcitabine treatment due to a femoral sarcoma. Both patients were admitted with a non-convulsive SE. Brain resonance MRI depicted bilateral, predominantly parietal-occipital lesions, hyperintense on T2/ fl uid attenuated inversion recovery and with no water restriction on diffusion-weighted MRI/apparent diffusion coeffi cient maps, consistent with vasogenic oedema ( fi gure 1 ); patient 2 also presented intracranial vasospasm on magnetic resonance angiography. Both patients were successfully treated for the SE with antiepileptic drugs plus blood pressure control and nimodipine. The fi rst patient repeated ABVD afterwards without recurrence of PRES. In the second patient, no further chemotherapy regimens were performed due to neoplasm refractoriness. Furthermore, both patients showed complete resolution of cytotoxic oedema on repeated MRI.The association between PRES and platinum, taxanes, vinca alkaloids, biological agents and combination chemotherapy, is increasingly recognised. The exact mechanism of toxicity remains unknown. Vasospasm and loss of cerebrovascular auto-regulation, with the development of vasogenic oedema is a hypothesis. If PRES is left untreated, cytotoxic oedema and permanent neurological defi cit may occur, 2 hence the need for an early recognition is required.

Vinblastine-induced posterior reversible encephalopathy syndrome

“…PRES has previously been reported in patients with HL; however, no single chemotherapeutic agent has consistently been implicated. 5,12 In our patient, the decision was to eliminate a single agent in order to assess resultant changes in neurological symptoms and MRI findings. Vinblastine was the first chemotherapeutic agent to be eliminated due to its association with peripheral neuropathy and the fact that vinca alkaloids are reported to be associated with PRES within the month preceding PRES.…”

“…As vinblastine has been associated with peripheral neuropathy, PRES has been reported in patients with HL undergoing ABVD treatment. 5 Here, we present a case of vinblastine-associated PRES in a patient with HL.…”

Posterior reversible encephalopathy syndrome presenting as refractory status epilepticus in a patient taking Mycophenolate mofetil for IgA nephropathy: A case report

“…Seizures are usually generalized and they occur in the acute stage of the disease, that commonly resolve within days. Refractory status epilepticus is a rare occurrence in PRES [ 4 , 5 ]. The treatment of PRES is aimed to identify underlying causes of the syndrome, and to control hypertension and seizures.…”

Posterior reversible encephalopathy syndrome and acute post-streptococcal glomerulonephritis mimicking breakthrough seizures

“…Raj et al ., in a study of 8 pediatric patients with PRES of diverse causes, found predominant generalized tonic and/or clonic seizures with no neurological sequel after 1 year follow up. 6 PRES presenting as status epilepticus has been documented in a previously healthy child, 7 two patients on chemotherapy, 8 after pediatric hematopoietic stem cell transplantation in 10 patients and in a further 10 cases where focal-onset complex partial seizure was present in the majority of cases. 9 PRES, in addition, can cause both convulsive and non-convulsive status epilepticus.…”