Posterior reversible encephalopathy syndrome and takotsubo cardiomyopathy associated with lenvatinib therapy for thyroid cancer: a case report and review

Abstract

As immunotherapies including tyrosine kinase inhibitors become more widely used for the treatment of a variety of malignancies, it is important for prescribers and patients to understand the potential adverse effects associated with these drugs. It is especially important to understand the potentially fatal side effects associated with these drugs to further determine risk factors for their development. The review presents a case of posterior reversible encephalopathy syndrome with concomitant Takotsubo cardiomyopathy, associated with use of lenvatinib therapy for thyroid cancer. It discusses the interventions performed and outcome. Potential mechanisms for development of these rare adverse effects, as well as cases in which these adverse effects are seen with use of other tyrosine-kinase inhibitors will be presented. It is important to continue to report these side effects, and further studies are needed to elucidate potential risk factors for their development, as well as to determine prognosis after development.

Acute heart and brain failure: a case report

“… 2 Reviewing data on PubMed, we identified another 8 case reports of associated PRES and TTS, resulting in a total of 14 patients. 2 , 12–19 Similar to our case, 13 of these 14 patients were female with an age range of 45–83 years 2 , 12–16 , 18 , 19 and 6 patients developed symptoms of TTS and PRES on the same day, 2 , 15–17 , 19 while 3 patients suffered from TTS first, 2 favouring the theory of a common pathogenesis over PRES triggering TTS.…”

“…Also similar to our case, a physical or emotional trigger was observed in 12 out of 14 patients. 2 , 12 , 14–16 , 18 , 19 An autoimmune disease as a potential trigger for endothelial dysfunction was present in seven patients and three had previously been treated with steroids. 2 , 12 The latter might serve as a trigger for TTS and PRES, since steroid-induced arterial hypertension is thought to be partially mediated by increased vascular sensitivity to adrenergic agonists.…”

“…The pathogenesis was suspected to be mediated by antagonism to vascular endothelial growth factor reducing nitric oxide through inhibition of nitric oxide synthase, which may cause an increased response to catecholamines in some organs. 18 …”

Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients

“…Several pathogenic mechanisms may accordingly converge on augmenting inflammatory processes and the synthesis and secretion of vascular endothelial growth factor (VEGF) by mesenchymal support cells, further serving to enhance the endothelial permeability and microcirculatory leakage. [2][3][4][5][6]14,47,50,52,105,115,122,125,[153][154][155] Curiously, Tlemsani et al 109 report on a cohort of patients receiving anti-VEGF therapy subsequently developing PRES, putatively consequent to the hypertensive effect of these agents. 109,156 Thus, the precise role of vasogenic growth factors in the pathogenesis of PRES remains to be more precisely elucidated.…”

Posterior Reversible Encephalopathy Syndrome Induced by Pazopanib in a Patient with Soft-Tissue Sarcoma: A Case Report

“…Commonly clinical manifestations of PRES include severe headache, confusion, seizures and visual disturbances, as well as signs of symmetrical white matter edema [3] under brain magnetic resonance imaging (MRI) study [1]. In the last few years an increased number of case reports involving new targeted drugs, particularly angiogenesis inhibitors such as sorafenib, sunitinib, pazopanib [4], regorafenib [5], lenvatinib [6] and other targeted drugs have been implicated in new cases of PRES [3]. This case represented a patient with hepatocellular carcinoma (HCC) under pazopanib using that developed multiple clinical adverse reactions including signal change under MR image study, which elicits highly suspicious of pazopanib induced PRES.…”