Posterior Reversible Encephalopathy Syndrome in an Elderly Patient with Acute Myeloid Leukemia

Case Report

Ann Hematol Onco. 2024; 11(1): 1445.

Posterior Reversible Encephalopathy Syndrome in an Elderly Patient with Acute Myeloid Leukemia

Stephen Lee Yu, MD, MS¹; Vishal Deepak, MD²; Salah Ud Din Safi, MD, MS¹; Rahul Sangani, MD³; Sarah Hadique, MD³

1West Virginia University Section of Hematology and Oncology, Department of Internal Medicine, USA

2Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University Langone Health, New York, USA

3West Virginia University, Section of Pulmonary Critical Care and Sleep Medicine, Department of Internal Medicine, USA

*Corresponding author: Stephen Lee Yu, MD, MS 64 Medical Center Drive, HSC, Division of Hematology/Oncology, PO Box 9162, 3rd Floor, Cancer Center, Rm 3911A, Morgantown, WV 26506, USA. Email: Stephen.yu@hsc.wvu.edu

Received: December 18, 2023 Accepted: January 12, 2024 Published: January 19, 2024

Abstract

Posterior Reversible Encephalopathy Syndrome (PRES) is a neurological condition presenting with encephalopathy, seizures and headache with concurrent edema in the posterior cerebral circulation. While hypertension is the most common associated, PRES has been reported in patients receiving chemotherapy for various cancers such as AML. We report a 61-year-old female with history of hypertension who presented with sepsis and a new diagnosis of Acute Myeloid Leukemia (AML). She was started on broad spectrum antibiotics for her sepsis concurrently with Azacitidine and Venetoclax for treatment of sepsis and AML, respectively. Shortly after initiation of her AML treatment, patient became encephalopathic and experienced tonic clonic seizures. She had clinical and imaging features consistent with PRES. PRES has been reported as rare complication of chemotherapy of various cancer generally, and AML specifically. It is important to recognize it in a timely manner to prevent further damage. This case report highlights this important complication of the chemotherapy initiation in AML especially in elderly patient who presented with sepsis.

Keywords: AML (Acute Myeloid Leukemia), PRES (Posterior reversible encephalopathy syndrome), case report, Azacitidine and Venetoclax

Abbreviations: AML: Acute Myeloid Leukemia; PRES: Posterior Reversible Encephalopathy Syndrome; CT: Computed Tomography; MR: Magnetic Resonance; MICU: Medical Intensive Care Unit

Introduction

Treatment of newly diagnosed Acute Myeloid Leukemia (AML) comes with myriad of different adverse effects based on the treatment regimen. This becomes especially important in advanced age population who often have poor tolerance to standard high-intensity chemotherapeutic agents. Azacitidine in combination with Venetoclax have shown good safety profile and well tolerated by elderly patients with AML, and even shown favorable overall response rate in untreated elderly AML patients [1,2]. While the safe profile in Azacitidine in combination with Venetoclax make it an optimal treatment of choice for advanced age population, post-marketing to look for further adverse effect is of critical importance. One of the rare side effect of treatments of AML is Posterior Reversible Encephalopathy Syndrome (PRES), which is a neurological condition characterized by headache, visual changes, seizures, and encephalopathy with concurrent symmetrical edema predominant in the posterior cerebral region seen in the Computed Tomography (CT) and Magnetic Resonance (MR) imaging [3]. To our knowledge, there has been one case report reported in two patients with AML, who developed PRES during induction chemotherapy [4]. Here, we present a case of elderly patient who have started treatment for newly diagnosed AML and developed PRES during treatment initiation with Azacytadine and Venetoclax.

Case Presentation

A 61-year-old female with history of hypertension presented to emergency department with complains of progressive fatigue, dyspnea, fever, hemoptysis, and increased bruising. Her vital signs at the time of presentation were within normal range and physical examination was notable for dried blood in both nares.

Laboratory findings at the time of presentation showed pancytopenia with white blood cell count of 0.9 x 103/μL, hemoglobin of 5.8 g/dL, and platelets of 5 x 103/μL. She was also noted to have mass like areas of similar size in the bilateral upper lobes concerning for atypical pneumonia on chest x-ray. Further evaluation with a Computed Tomography (CT) chest showed ill-defined alveolar density in the bilateral upper lobes, more pronounced near the left apex concerning for multifocal pneumonia with underlying pulmonary mass at the lung apices (Figure 1).

Citation: Yu SL, Deepak V, Ud Din Safi S, Sangani R, Hadique S. Posterior Reversible Encephalopathy Syndrome in an Elderly Patient with Acute Myeloid Leukemia. Ann Hematol Onco. 2024; 11(1): 1445.