Posterior Reversible Encephalopathy Syndrome (PRES) in a Patient with Metastatic Gastric Cancer While Receiving FOLFIRI Chemotherapy: A Case Report

Abstract

Introduction: Gastric cancer is one of the most common cancers worldwide. Approximately 50 percent of patients have a metastatic disease at presentation. In these situations, the goals of therapy include palliation of symptoms and prolongation of survival with either local methods or systemic therapies. FOLFIRI (Folinic acid, Fluorouracil, Irinotecan) is a chemotherapy protocol that has been used in gastrointestinal malignancies. Neurological symptoms are not unexpected in patients with cancers receiving chemotherapy, however the development posterior reversible encephalopathy syndrome (PRES) in such patients without significant elevation of blood pressure is extremely rare and only documented in few cases. Case report: A 28-years-old female, known to have benign essential hypertension, and metastatic gastric cancer to the peritoneum. She was admitted with abdominal pain associated with vomiting for one week. CT scan of the abdomen was suggestive of partial intestinal obstruction presumed to be due to her cancer. The decision was to continue bowel rest and IV hydration, and then to start palliative chemotherapy (FOLFIRI). The patient received the first cycle, followed by the second cycle after 2 weeks. During that time, her nausea and vomiting had worsened after a transient improvement, requiring multiple antiemetics. On day 2 of her second cycle, she had 3 generalized tonic seizures with up rolling of the eyes and stool incontinence. Brain MRI with contrast showed multiple bilateral cortical and subcortical T-2 hyper intense lesions in the parietal and occipital lobes, as well as the cerebellar hemisphere. The image was negative for ischemic changes, surrounding edema, intracranial hemorrhage, space occupying lesion, or midline shift. These finding were consistent with posterior reversible encephalopathy syndrome. No significant elevation of blood pressure was noted. Subsequently, the patient developed acute respiratory failure associated with cardiogenic and septic shock. She was transferred to the intensive care unit and died after few days of her transfer. Conclusion: Here, we describe a rare case of PRES developed in a patient with gastric cancer while receiving FOLFIRI chemotherapy. PRES is a clinical radiographic syndrome of heterogeneous etiologies that have similar findings on neuroimaging studies. Whether it's related only to chemotherapy or combined effect of gastric cancer and chemotherapy is unknown. It requires further studies.Figure 1