Reversible posterior leukoencephalopathy syndrome following combinatorial cisplatin and pemetrexed therapy for lung cancer in a normotensive patient: A case report and literature review

Abstract

Abstract. Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare neurological syndrome of the brain, causing symptoms such as headaches, seizures, altered mental status and visual disturbances. The condition is predominantly associated with hypertension, eclampsia, renal impairment, cytotoxic drugs, immunosuppressive agents and molecular targeted agents, but the precise underlying mechanism of RPLS is not fully understood. The present study describes the case of a 65-year-old female patient with stage IIA non-small cell lung cancer who received cisplatin/pemetrexed treatment at the Leo W. Jenkins Cancer Center. Following 3 cycles of this therapy, the patient was referred to the Emergency Department of Vidant Medical Center with an altered mental status, subsequently presenting with epileptic seizures, a fever and a headache. A neurological examination revealed generalized hyperreflexia and paraparesis, with extensor posturing of the bilateral lower extremities. The lumbar puncture and electroencephalography results were normal, but cranial computed tomography (CT) scans revealed attenuation abnormalities in the bilateral parietal region and the left occipital lobe, with suspected metastasis. Cranial T2-weighted magnetic resonance imaging (MRI) indicated bilateral regions of increased signal intensity in the occipital, temporal and periventricular white matter. The patient was treated with anticonvulsants, steroids and antihypertensive drugs, recovered gradually from the symptoms and regained full consciousness. However, the patient reported residual weakness, presenting with an Eastern Cooperative Oncology Group score of 3, reflective of an inability to independently perform daily activities and self-care. A brain MRI performed 10 days later demonstrated that the subcortical edema had partially subsided. The patient was discharged on day 15 post-admission. A follow-up cranial CT examination 1 month later indicated a partial resolution of the abnormalities. The present report reviews similar associated cases, and also discusses the clinical features and mechanisms underlying RPLS. Although it is typically reversible, RPLS is a serious and potentially life-threatening adverse condition if left untreated. Early recognition of this condition is crucial for the prompt control of the patient's blood pressure or withdrawal of cytotoxic drugs in order to reverse this syndrome. IntroductionReversible posterior leukoencephalopathy syndrome (RPLS) was first described by Hinchey et al (1) as an acute illness that causes symptoms such as hypertension, headaches, seizures, altered mental status and visual disturbances, and which is usually reversible following the removal of the causative agents and the control of the patient's blood pressure. RPLS is characterized by white matter edema, particularly involving the bilateral occipital and posterior parietal lobes of the brain (1). Involvement of other areas of the brain, including the frontal lobes, cerebellum, basal ganglia and brain stem, has also been reported.R...

Magnetic resonance imaging of leukoencephalopathy in amnestic workers exposed to organotin

“…Acute Marchiafava-Bignami disease (Wenz et al, 2014) in alcoholic patients, the early stages of 5-fluorouracil-induced leukoencephalopathy (Bang et al, 2012) in cancer patients, hypoglycemic encephalopathy (Ma et al, 2009), and reversible posterior leukoencephalopathy syndrome (Xie and Jones, 2016) may have similar patterns of lesions in the corpus callosum and white matter on MRI. However, occupational history and clinical characteristics can differentiate these conditions from leukoencephalopathy due to organotin intoxication.…”

Posterior Reversible Encephalopathy Syndrome after Lenvatinib Therapy in a Patient with Anaplastic Thyroid Carcinoma

“…In the present case, a 7-day interruption in therapy allowed for the resolution of PRES symptoms and MRI findings, suggesting that lenvatinib treatment was the cause of PRES. One study suggested that severe hypertension causing vasogenic edema can also precipitate PRES ( 20 ). It is unlikely that PRES was directly caused by severe hypertension - independent of lenvatinib use - in the present case, as the PRES symptoms disappeared during the suspension of lenvatinib treatment and reappeared after its re-initiation, despite the patient's recurrent severe hypertension.…”

A Case of Posterior Reversible Encephalopathy Syndrome Induced by Cisplatin/Pemetrexed Chemotherapy for Lung Cancer

“…Since the present case of PRES was a patient treated with CDDP/Pem, it is difficult to determine which anticancer drug was responsible. In 2016, Xie and Jones [ 9 ] reported a case of PRES associated with CDDP/Pem, which was concluded to be caused by CDDP based on the absence of previous reports of PRES related to Pem alone. In 2009, Nguyen et al [ 10 ] also reported a case of PRES associated with CDDP/Pem, which was attributed to neurotoxicity of CDDP enhanced by dexamethasone for treating nausea and vomiting.…”