PRES, the most uncommon side effect of one of the

commonest chemotherapy regimen, FOLFOX

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Case Report

PRES, the most uncommon side effect of one of thecommonest chemotherapy regimen, FOLFOX

Viraj Lavingia a,*, Boman Dhabhar b, Mudhasir Ahmad a

a DNB Medical Oncology Fellow; Apollo Hospitals, Jubilee Hills, Hyderabad, Indiab Consultant Medical Oncologist, Fortis Hospital, Mulund, Mumbai, India

a r t i c l e i n f o

Article history:

Received 17 December 2014

Accepted 3 February 2015

Available online xxx

Keywords:

PRES

FOLFOX

Colorectal cancer

* Corresponding author. Department of MedIndia. Tel.: þ91 9908711057 (mobile).

E-mail address: drvirajlavingia@gmail.co

Please cite this article in press as: Lavingtherapy regimen, FOLFOX, Apollo Medici

http://dx.doi.org/10.1016/j.apme.2015.02.0020976-0016/Copyright © 2015, Indraprastha M

a b s t r a c t

Introduction: Posterior reversible encephalopathy syndrome (PRES), is a syndrome charac-

terized by headache, confusion, seizures and visual loss, which was first described in 1996

by Judy Hinchey. The cause of PRES is not yet understood. We report a case of a 50-year-old

man that developed PRES after the use of mFOLFOX 6 (Oxaliplatin/5-Fluoracil/Leucovorin)

chemotherapy for colorectal cancer.

Case report: An adult patient of colorectal cancer underwent resection of the primary tumor

followed by adjuvant chemotherapy with mFOLFOX 6. Five days after the eleventh cycle he

presented with headache and ataxia. A brain MRI (FLAIR/T2) was performed the same day

which showed an increase of signal in both cerebellar lobes. Diagnosis of PRES was made

by the radiologist. His symptoms started to improve after 3 days of hospitalization, and he

was discharged after five days of hospital stay. A repeat MRI after 2 weeks revealed com-

plete resolution of the hyper intense lesions in bilateral cerebellar lobes.

Conclusion: Oncologists must be aware of this uncommon but specific adverse effect of

FOLFOX chemotherapy, as prompt diagnosis may result in complete resolution of PRES.

Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Posterior reversible encephalopathy syndrome (PRES), also

known as reversible posterior leukoencephalopathy syn-

drome (RPLS), is a syndrome characterized by headache,

confusion, seizures and visual loss, which was first described

in 1996 by Judy Hinchey.1 The cause of PRES is not yet un-

derstood. We report a case of a 50-year-old man that devel-

oped PRES after the use of mFOLFOX 6 (Oxaliplatin/5-

Fluoracil/Leucovorin) chemotherapy for colorectal cancer.

ical Oncology, Apollo Ca

m (V. Lavingia).

ia V, et al., PRES, the mne (2015), http://dx.doi.o

edical Corporation Ltd. A

2. Case report

A 50-year-oldman, non hypertensive, non diabetic, presented

with colorectal adenocarcinoma (T2N1; clinical stage III). He

underwent resection of the primary tumor 6 months before

the admission and he underwent adjuvant chemotherapy

with mFOLFOX 6 (Oxaliplatin/5-fluorouacil/Leucovorin). Five

days after the eleventh cycle he presented with headache and

ataxia. On examination there was left plantar extensor and

cerebellar ataxia. He had no fever or any seizure episodes and

ncer Hospital, Apollo Hospital, Jubilee Hills, Hyderabad 500096,

ost uncommon side effect of one of the commonest chemo-rg/10.1016/j.apme.2015.02.002

ll rights reserved.

Fig. 1 e Bilateral cerebellar hyperintensities.

Fig. 2 e Significant reduction of bilateral cerebellar

hyperintensities.

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e32

his basic blood tests showed no abnormalities. However he

had mildly raised blood pressure (160/90 mmHg). A brain MRI

(FLAIR/T2) (Fig. 1) was performed the same day which showed

an increase of signal in both cerebellar lobes. Diagnosis of

PRES wasmade by the radiologist. MR Angio of brain and neck

vessels was normal. 2D-Echocardiogram was normal too. He

was treated with antihypertensive medications and support-

ive care. No antiplatelets or anticoagulants were used. His

symptoms started to improve after 3 days of hospitalization,

and hewas discharged after five days of hospital stay. A repeat

MRI (Fig. 2) after 2 weeks revealed complete resolution of the

hyper intense lesions in bilateral cerebellar lobes.

3. Discussion

Posterior reversible encephalopathy syndrome (PRES) was

first described in 1996 by Judy Hinchey.1 The most common

abnormality on neuroimaging is edema involving the white

Fig. 3 e Table depicting all 5

Please cite this article in press as: Lavingia V, et al., PRES, the mtherapy regimen, FOLFOX, Apollo Medicine (2015), http://dx.doi.o

matter in the posterior portions of the cerebral hemispheres,

especially bilaterally in the parieto-occipital regions. Involve-

ment of additional areas such as the brain stem, cerebellum,

basal ganglia, and frontal lobes, has also been reported.

Common causes include hypertension, renal failure and

certain drugs. No specific drug has shown to be consistently

associated with this adverse effect. We did a literature search

on PUBMED, and there are only 5 cases of PRES associatedwith

FOLFOX which have been reported.

As shown in Table (Fig. 3), all the five cases had metastatic

disease for which FOLFOX chemotherapy was given, and all

the cases had PRES either in occipital lobes or parieto-occipital

region. This case stands out for two reasons, 1) the site of PRES

and 2) adjuvant nature of the chemotherapy.

Stopping of the offending drug usually results in complete

resolution of PRES. Also re-introduction of the same drugmay

cases so far reported.2e6

ost uncommon side effect of one of the commonest chemo-rg/10.1016/j.apme.2015.02.002

a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1e3 3

lead to recurrence of PRES. In summary, oncologists must be

aware of this uncommonbut specific adverse effect of FOLFOX

chemotherapy, as prompt diagnosis may result in complete

resolution of PRES.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. Hinchey Judy, Chaves Claudia, Appignani Barbara, et al. Areversible posterior leukoencephalopathy syndrome. N Engl JMed. 1996;334:494e500.

Please cite this article in press as: Lavingia V, et al., PRES, the mtherapy regimen, FOLFOX, Apollo Medicine (2015), http://dx.doi.o

2. Skelton MR, Goldberg RM, O'Neil BH. A case of oxaliplatin-related posterior reversible encephalopathy syndrome. ClinColorectal Cancer. 2007 Jan;6:386e388.

3. Nagata Y, Omuro Y, Shimoyama T, et al. A case of colon cancerwith reversible posterior leukoencephalopathy syndromefollowing 5-FU and oxaliplatin (FOLFOX regime). Gan To KagakuRyoho. 2009 Jul;36:1163e1166.

4. Kim CH, Kim CH, Chung CK, Jahng TA. Unexpected seizureattack in a patient with spinal metastasis diagnosed asposterior reversible encephalopathy syndrome. J KoreanNeurosurg Soc. 2011 Jul;50:60e63.

5. Matsunaga M, Miwa K, Araki K, et al. A case of reversibleposterior leukoencephalopathy syndrome (RPLS) induced bymodified FOLFOX. Gan To Kagaku Ryoho. 2012Aug;39:1283e1286.

6. Porcello Marrone LC, Marrone BF, Pascoal TA, et al. Posteriorreversible encephalopathy syndrome associated with FOLFOXchemotherapy. Case Rep Oncol Med. 2013;2013:306983.

ost uncommon side effect of one of the commonest chemo-rg/10.1016/j.apme.2015.02.002

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