Posterior reversible encephalopathy syndrome while receiving irinotecan with fluorouracil and folinic acid for metastatic gastric cancer

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome with seizures, headache, altered mental status and visual disturbances. It is typically associated with posterior cerebral white matter oedema on neuroimaging. There is an increasing number of cases of PRES reported with different chemotherapeutic protocols. However, PRES is rarely reported in association with irinotecan, fluorouracil and folinic acid (FOLFIRI). We report a 28-year-old female patient with a history of Stage IV gastric cancer who presented with abdominal pain and recurrent vomiting that was thought to be related to a partial intestinal obstruction secondary to peritoneal metastasis. Eventually, she was treated with FOLFIRI. A few hours after initiation of the fluorouracil infusion in the second cycle, she developed a tonic-clonic seizure. MRI of the brain showed multiple bilateral T ₂ and flair hyperintense cortical and subcortical lesions suggestive of PRES. Other causes of PRES were excluded, as well as brain metastasis. Unfortunately, the patient developed septic shock and died a few days after her presentation.

Figure 1.

Brain MRI with contrast. (a) T₁ sequence, (b) T₂ sequence, (c) T₂-flair sequence. These sequences show multiple bilateral T₂ and flair hyperintense cortical and subcortical lesions in the parietal and occipital lobes, as well as in the cerebellar hemispheres. Some lesions showed minimal enhancement. No significant surrounding oedema, intracranial haemorrhage, space-occupying lesions, hydrocephalus or midline shift are seen.