Reversible posterior leukoencephalopathy syndrome and anti-neoplastic agents: a review

Shah-Khan, Farheen; Pinedo, Daryl; Shah, Prabodh

doi:10.1007/s12156-007-0018-0

Cited by 16 publications

(5 citation statements)

References 64 publications

(15 reference statements)

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“…PRES has been associated with exposure to corticosteroids, cytotoxic chemotherapy, IST, and targeted therapy (12). PRES may occur even several months after drug exposure and with serum drug concentrations within the normal range (3), such as in the cases where chemotherapy is used as a single agent or after a multi-drug regimen (12,23). Shah-Khan et al proposed criteria for anti-neoplastic PRES, including exposure to medications for up to 4 months before PRES (23).…”

Section: Discussionmentioning

confidence: 99%

“…PRES may occur even several months after drug exposure and with serum drug concentrations within the normal range (3), such as in the cases where chemotherapy is used as a single agent or after a multi-drug regimen (12,23). Shah-Khan et al proposed criteria for anti-neoplastic PRES, including exposure to medications for up to 4 months before PRES (23). Several studies have implicated specific drugs as offenders; however, it is difficult to generalize these findings because most patients receive multi-drug therapies over a long period of time.…”

Section: Discussionmentioning

confidence: 99%

“…Nephrotoxicity, neurotoxicity, and severe HTN are major side effects of CsA (25,26). CsA neurotoxicity may be exacerbated in the presence of hypomagnesemia, hypocholesterolemia, and HTN (23,25). In turn, CsA may further aggravate HTN through central and peripheral mechanisms (27).…”

Section: Discussionmentioning

confidence: 99%

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Different Clinicoradiological Characteristics of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncology and Post-Bone Marrow Transplantation Cases: A Retrospective Study

et al. 2022

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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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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Different Clinicoradiological Characteristics of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncology and Post-Bone Marrow Transplantation Cases: A Retrospective Study

et al. 2022

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“…With regards to chemotherapy agents, cytarabine and methotrexate given orally, parenterally or intrathecally are implicated with PRES [14]. Cytarabine administered intrathecally is generally reported with PRES rather than when administered by the intravenous route, although cytarabine rapidly distributes into the CSF and when given intravenously in high doses, it could potentially causes neurotoxicity [15].…”

Section: Discussionmentioning

confidence: 99%

Posterior reversible encephalopathy syndrome as the initial presentation of acute lymphoblastic leukaemia

Fadilah

2011

J Hemat Malig

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Posterior reversible encephalopathy syndrome (PRES) is a recognized complication of chemotherapy. However, the development of PRES at presentation of acute lymphoblastic leukemia (ALL) is rare. Here we discuss the uncommon presenting feature of PRES in ALL, and its progression with chemotherapy.A 13-year-old Malay male presented with a one-week history of blurred vision and headache associated with hypertension, hyperkalemia and acute renal failure. CT brain imaging showed symmetrical and bilateral white matter hypodensities at the parietal regions. Brain MRI on T2 and FLAIR images showed patchy areas of high signal intensity at cortical and subcortical region of both parietal and occipital lobes, consistent with PRES. He developed bicytopenia and bone marrow biopsy confirmed pre-B acute lymphoblastic leukemia. He received Phase 1 induction chemotherapy according to the modified UKALL XII protocol but in view of PRES, L-asparaginase and intrathecal methotrexate were delayed until after Day 17 of chemotherapy. No neurological symptoms were observed after chemotherapy. However, during Phase 2 induction chemotherapy with high dose cytarabine and intrathecal methotrexate, he developed accelerated hypertension and status epilepticus requiring mechanical ventilation. Cerebrospinal fluid analysis did not show infection or leukemic infiltration. A repeat brain MRI showed worsening features of the pre-existing PRES, followed by partial resolution on Day 37 of chemotherapy. Subsequent cytotoxic chemotherapies were uneventful except for radiological deterioration of PRES with partial resolution upon hematological recovery.It is important to consider the diagnosis of PRES in a young patient presenting with acute onset of headache and visual disturbances even before the initiation of cytotoxic chemotherapy. In view of the pre-existing PRES, there are risks of further neurological damage and fatal neurological squeal by introducing chemotherapy to treat the leukemia. Therefore it is vital to recognize and treat PRES promptly as early intervention may prevent or reverse the development of encephalopathy.

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“…Furthermore, external factors also contributing to this pathway could increase the risk of methotrexate toxicity. These include low B 12 levels, 5 concurrent or previous cyclosporine treatment, other immunosuppressants, cytotoxic medication, 6,7 drug interactions (e.g., omeprazole, which can increase methotrexate levels 8 ), and genetic polymorphisms altering methotrexate metabolism and transport. 9 Despite a reasonable assumption that the risk of toxicity should increase with total cumulative dose or duration of methotrexate treatment, these were highly variable in the reported cases, suggesting no clear association between clinical risk, duration, and dose of treatment.…”

Section: Questions For Considerationmentioning

confidence: 99%

Clinical Reasoning: Progressive visuospatial problems in a 71-year-old man

2014

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A 71-year-old right-handed man presented with a 3-month history of progressive cognitive impairment. Six weeks before presentation, he became unable to use his mobile phone, with difficulties pressing the digits in the correct order. He had developed problems reading, describing a jumbledup appearance of words on the page. He omitted single letters when writing, and had difficulty in using cutlery and accurately judging portion sizes. He had ceased driving due to navigational problems and because of repeatedly hitting the curb. In the last 4 weeks, he had developed difficulty dressing. Notably, he had good insight, being able to give a detailed description of symptoms.Four years earlier, the patient had been diagnosed with rheumatoid arthritis (RA) and commenced immunomodulatory therapy with methotrexate (15 mg/wk plus folic acid 5 mg/wk) and hydroxychloroquine (200 mg/d). One year later, following an exacerbation of joint symptoms and the development of interstitial lung disease thought to be a systemic complication of RA, his methotrexate dose was increased to 25 mg/wk (subcutaneously) and leflunomide (10 mg/d) was added. At presentation, he remained on methotrexate and hydroxychloroquine at the same doses, but leflunomide had been discontinued and sulfasalazine (3 g daily) commenced. The only other history of note was an episode of obstructive cholestasis. He was otherwise well, and the main carer for his wife.Examination revealed marked visuospatial dysfunction and simultanagnosia. The patient was able to read when presented with one line of text, but unable to read a paragraph. Object recognition was preserved; however, he was unable to describe a picture of a scene. He could not recognize interrupted figures or letters. He had an ideomotor limb apraxia, with impaired gesture copying (e.g., extending the 1st and 2nd digits at right angles). He scored 16/30 on the Montreal Cognitive Examination (MoCA), with severe constructional apraxia, being unable to draw a cube or clock, performing poorly on the Trail-Making Test (figure, A), and additional impairments on vigilance testing and serial 7s, reduced verbal fluency, and impaired delayed recall. There was no dysgraphesthesia or neglect. Speech was intact, and he could understand and follow written commands. There were no parkinsonian features and the remainder of the neurologic examination was normal. Systemic examination revealed bibasal lung crepitations. His admission blood pressure was 128/75 mm Hg. There was no clinical evidence of active joint inflammation.

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Reversible posterior leukoencephalopathy syndrome and anti-neoplastic agents: a review

Cited by 16 publications

References 64 publications

Different Clinicoradiological Characteristics of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncology and Post-Bone Marrow Transplantation Cases: A Retrospective Study

Different Clinicoradiological Characteristics of Posterior Reversible Encephalopathy Syndrome in Pediatric Oncology and Post-Bone Marrow Transplantation Cases: A Retrospective Study

Posterior reversible encephalopathy syndrome as the initial presentation of acute lymphoblastic leukaemia

Clinical Reasoning: Progressive visuospatial problems in a 71-year-old man

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