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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 103-105

Identification and Management of Posterior Reversible Encephalopathy Syndrome in a Patient Enrolled in an Immunotherapy Combination Phase I Clinical Trial: A Case Study

Department of Investigational Cancer Therapeutics (A Phase I Program), University of Texas MD Anderson Cancer Center, Houston, TX, USA

Date of Submission15-Jul-2020
Date of Acceptance16-Sep-2020
Date of Web Publication21-Nov-2020

Correspondence Address:
PhD, ANP-BC, AOCNP Fedricker D Barber
Department of Investigational Cancer Therapeutics (A Phase I Program), University of Texas MD Anderson Cancer Center, Houston, TX
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/apjon.apjon_49_20

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Posterior reversible encephalopathy syndrome (PRES) is a rare potential immune-related adverse event (irAE) of checkpoint inhibitors. PRES is a disorder that has a variety of clinical and radiological features, which makes it a challenge for advanced practice registered nurses to diagnose. IrAEs such as PRES require prompt recognition and intervention to optimize clinical outcomes.
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Keywords: Checkpoint inhibitors, Phase I clinical trial, posterior reversible encephalopathy syndrome

How to cite this article:
Barber FD. Identification and Management of Posterior Reversible Encephalopathy Syndrome in a Patient Enrolled in an Immunotherapy Combination Phase I Clinical Trial: A Case Study. Asia Pac J Oncol Nurs 2021;8:103-5

How to cite this URL:
Barber FD. Identification and Management of Posterior Reversible Encephalopathy Syndrome in a Patient Enrolled in an Immunotherapy Combination Phase I Clinical Trial: A Case Study. Asia Pac J Oncol Nurs [serial online] 2021 [cited 2021 Aug 5];8:103-5. Available from: https://www.apjon.org/text.asp?2021/8/1/103/301136

  Introduction Top

Phase I clinical trials are conducted to explore safety, tolerability, adverse events (AEs), and the pharmacokinetics of novel drugs.[1] Recently, Phase I clinical trials have consisted of immune checkpoint inhibitors (ICIs) in combination with radiation, molecularly targeted therapies, or other immunotherapy agents.[2] These ICI combination trials have the potential for therapeutic synergy, however, often, the benefits of ICIs can be equipoised by rare immune-related AEs (irAEs) such as posterior reversible encephalopathy syndrome (PRES).[3],[4]

  Case Report Top

A 50-year-old female with refractory high-grade neuroendocrine carcinoma of the retroperitoneum currently cycle 2, day 8 of an ICI combination Phase I clinical trial, presented to the emergency center through ground ambulance with new-onset grand mal seizure with generalized tonic-clonic activity, severe headache, nausea, and vomiting. Of note, the patient's family reported a 2-week history of poor oral intake of food and water by the patient. The patient received Versed in route to the hospital. On arrival, the patient did not have any seizure activity and was arousable but confused. Physical examination in the emergency center revealed: heart rate of 139/min, blood pressure of 132/95 mmHg, respiration rate of 18/min, temperature of 36.7°C, and oxygen saturation of 100%. Blood work demonstrated glucose of 106, CO2 of 21, chloride of 98, potassium of 3.6, sodium of 134, creatinine of 4.95, magnesium of 2.3, ammonia of 29, lactic acid of 0.6, antineutrophil antibody vasculitis panel negative, and ANA titer <1:40. Magnetic resonance imaging (MRI) of the brain without contrast showed scattered, symmetrical T2 fluid-attenuated inversion recovery hyperintensity within bilateral posterior cerebral hemispheres without associated infarct or hemorrhage. In the emergency center, the patient was treated with Ativan and Keppra intravenously (IV), a consult was placed for neurology. Subsequently, the patient was placed on Vimpat 100 mg twice/day orally. She did not have any additional seizure episodes and did not require any immunosuppressants. While hospitalized, the patient became hypertensive, with systolic blood pressures ranging between 140 and 170 mmHg. The patient was initially started on Hydralazine 50 mg three times a day and Labetalol 20 mg every 8 h as needed, which was later changed to Nifedipine 20 mg daily with adequate control of blood pressure. A nephrologist was consulted to manage the acute kidney injury (AKI). Renal ultrasound showed increased renal echotexture. Lactic acidosis, starvation ketosis, and infection were ruled out as a cause of the AKI. The patient was treated with gentle IV hydration. She made a full recovery and was discharged from the hospital. Subsequently, she was seen in the clinic with a follow-up MRI of the brain, which showed complete resolution of the T2 abnormality. Nonetheless, the patient was removed from the Phase I clinical trial secondary to PRES. Informed consent was obtained from the patient.

  Discussion Top

The exact underlying pathophysiology of PRES is not well known, although it is believed to be secondary to rapidly developing hypertension that exceeds the upper limits of cerebral blood flow autoregulation that causes hyperperfusion, which leads to the dysfunction of the blood–brain barrier, thus allowing the interstitial extravasation of plasma and macromolecules.[5],[6] PRES is often seen in young or middle-aged adults with an incidence rate that varies from 2% to 25%.[5] In addition, PRES has been associated with chronic and acute kidney disease, solid organ transplantation, and use of immunosuppressive drugs.[5],[7]

PRES can be a challenge to diagnose because of the variety of neurological signs and symptoms, which can develop within hours or several days or weeks.[6] However, PRES should be considered in patients who present with seizures, altered consciousness, visual disturbance, or headache, particularly in the context of acute hypertension.[6] Although most patients are likely to present with hypertension, approximately 15% to 20% of patients may be normotensive or hypotensive during the initial evaluation.[4] Given that the signs and symptoms of PRES are nonspecific, advanced practice registered nurses (APRN) are challenged to distinguish PRES from other neurological diseases. The differential diagnosis of PRES might include reversible cerebral vasoconstriction syndrome, infectious encephalitis, malignant tumor, or other vasculitis process.[6] A trigger is usually identifiable, most commonly acute hypertension, but patients often have other comorbidities or medications that may predispose them to developing PRES.[6]

There are no laboratory findings specific to PRES. If an APRN suspects PRES, brain imaging is needed to exclude differential diagnoses.[6] In general, radiologic findings of PRES show regions of T2 signal abnormality on the MRI.[6] Other potential findings that are seen with the brain MRI include a dominant parieto-occipital pattern, holohemispheric watershed pattern, and superior frontal sulcus pattern.[6]

There is no specific treatment for PRES, however if recognized and treated promptly, the rapid onset of symptoms and radiologic features usually fully resolve within days to weeks.[6] Yet, >10%–44% of patients may experience persistent neurologic deficits if treatment is delayed.[8] In addition, PRES can reoccur with an overall mortality of 3%–6%.[6]

In general, the APRN will prescribe antiepileptic drugs for seizures as they would in any other neurological disorder, which can be tapered as soon as the patient is asymptomatic, and the imaging lesions have fully reversed.[6],[9] Specific antihypertensive medications have not been fully evaluated in the treatment of hypertensive encephalopathy in PRES, therefore the selection of drugs is based on the APRN's preference and recommended treatment guidelines.[10] If the APRN suspects that PRES is caused by a specific medication, then the medication should be temporarily placed on hold or discontinued permanently.

  Conclusions Top

IrAEs such as PRES require prompt recognition and intervention to optimize clinical outcomes. As ICI enters day-to-day clinical practice, it is crucial that multidisciplinary collaborations are established to improve the recognition and management of common or rare irAEs. Thus, as part of the multidisciplinary team, APRNs should become familiar with irAEs to facilitate proper evaluation and referral to the correct specialist.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

West H, Dahlberg S. Clinical trials, end points, and statistics-measuring and comparing cancer treatments in practice. JAMA Oncol 2018;4:1798.  Back to cited text no. 1
Emens LA, Butterfield LH, Hodi FS Jr, MarincolaFM, KaufmanHL. Cancer immunotherapy trials: Leading a paradigm shift in drug development. J Immunother Cancer 2016;4:42.  Back to cited text no. 2
Myers G. Immune-related adverse events of immune checkpoint inhibitors: A brief review. Curr Oncol 2018;25:342-7.  Back to cited text no. 3
Kim D. Posterior reversible encephalopathy syndrome induced by nivolumab immunotherapy for non-small-cell lung cancer. Clin Case Rep 2019;7:935-8.  Back to cited text no. 4
Pilato F, Distefano M, Calandrelli R. Posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome: Clinical and radiological considerations. Front Neurol 2020;11:34.  Back to cited text no. 5
Fugate JE, Rabinstein AA. Posterior reversible encephalopathy syndrome: Clinical and radiological manifestations, pathophysiology, and outstanding questions. Lancet Neurol 2015;14:914-25.  Back to cited text no. 6
Alvarado Verduzco H, Acharya A. Acute kidney injury, recurrent seizures, and thrombocytopenia in a young patient with lupus nephritis: A diagnostic dilemma. Case Rep Nephrol 2016;2016:7104098.  Back to cited text no. 7
Hinduja A, Habetz K, Raina S, Ramakrishnaiah R, Fitzgerald RT. Predictors of poor outcome in patients with posterior reversible encephalopathy syndrome. Int J Neurosci 2017;127:135-44.  Back to cited text no. 8
Fischer M, Schmutzhard E. Posterior reversible encephalopathy syndrome. J Neurol 2017;264:1608-16.  Back to cited text no. 9
Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2018;138:e426-83.  Back to cited text no. 10


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