Cabozantinib
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First report of atypical posterior reversible encephalopathy syndrome secondary to hypertension: case report A 70-year-old woman developed atypical posterior reversible encephalopathy syndrome (PRES) secondary to hypertension during treatment with cabozantinib for metastatic renal cell cancer. The woman presented with confusion and seizures preceded by nausea and vomiting. Her medical history was significant for right-sided metastatic renal cell carcinoma, chronic kidney disease and essential hypertension. She had been receiving oral palliative cabozantinib [dosage not stated]. Her past diagnosis was right-sided renal cell carcinoma with metastasis to the thoracic spine resulting in compression fracture requiring laminectomy and radiation therapy. She had undergone right-sided nephrectomy due to a spontaneous subscapular perinephric hematoma. Initially, she was treated with Ipilimumab/nivolumab followed by nivolumab for 7 months. Thereafter, she was initiated cabozantinib 3 weeks prior to the hospital admission because of disease progression. While reaching to the hospital, she had an episode of seizure in the ambulance, which was treated with lorazepam. At presentation, her heart rate was of 107. She was afebrile with blood pressure of 185/96mm Hg and respiratory rate of 28 /min. She was quite somnolent on initial examination, and pupils were 4mm and sluggishly reactive. Thereafter, she was intubated to protect her airway. The woman was started on levetiracetam for seizures, and nicardipine was given for uncontrolled blood pressure. EEG demonstrated symmetric, nonspecifically slow, mixed-frequency activities partly reflecting effects of pharmacologic sedation; however, there was no definite epileptiform activity. MRI of the brain revealed multiple patchy subcortical T2/FLAIR hyperintense foci involving the frontal lobe parietal lobe, temporal lobe, and occipital lobe. The T2 hypertense focus in the left temporal lobe had diffusion restriction. There was a diffuse mild leptomeningeal enhancement in the right frontal lobe, right parietal lobe, right temporal lobe and bilateral occipital lobes. She was diagnosed with atypical PRES. Her presentation was felt to be secondary to uncontrolled hypertension due to cabozantinib. Due to the high blood pressure, she was treated with nicardipine followed by metoprolol and amlodipine. She did not have further recurrence of seizures while in the hospital and was extubated within 24 hours. Her mental status gradually improved. Cabozantinib was discontinued. Levetiracetam kept continued even after discharge. She was scheduled with a follow-up MRI of the brain in 3 months to look for resolution of MRI findings. However, her disease had progressed, and she opted an hospice care Patwari A, et al. Atypical Posterior Reversible Encephalopathy Syndrome due to Oral Tyrosine Kinase Inhibitor Cabozantinib: First Case Report. Case Reports in Oncology 803518691 13: 1013-1019, No. 2, 2020. Available from: URL: http://doi.org/10.1159/000509640
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