Capecitabine
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Various toxicities: case report An approximately 60-year-old woman developed asthenia, mucositis, vomiting and diarrhoea, neutropenia and posterior reversible encephalopathy syndrome (PRES) during treatment with capecitabine. The woman, at the age of 50 years in June 2007, underwent left mastectomy and axillary lymphadenectomy for hormone receptor-positive breast cancer. At that time, she received induction chemotherapy including epirubicin, paclitaxel, and then highdose-dense chemotherapy with epirubicin and dexrazoxane followed by blood stem cell reinfusion. For 5 years, she had received tamoxifen and adjuvant radiation therapy. In July 2015, she was diagnosed with diffuse vertebral metastases. Therefore, she received treatment with denosumab, and palliative chemotherapy with vinorelbine, levofolinic-acid [calcium levofolinate] and fluorouracil [5-FU] for 6 cycles, obtaining a partial response. As maintenance therapy, she received letrozole. In October 2017, following an increase in Ca 15–3 levels, she was initiated with capecitabine 2500 mg/m2 days 1–14, every 3 weeks. Following 8 days of treatment, she was admitted to the oncology ward because of grade 2 asthenia, grade 2 mucositis, grade 2 vomiting and grade 3 diarrhoea. Subsequent physical examination was unremarkable. At that time, she seemed to be in a slightly confused state. Blood test showed neutrophil count 500 x 109/L, decreased haemoglobin (10.9 g/dL), platelet count 79 x 109/L, creatinine 0.72 mg/dL and velocity of glomerular filtration (eGFR) was 91 mL/min/1.73m2. Rectal swab and stool sample for bacterial culture returned negative. Following her admission, capecitabine was stopped and treatment with ceftriaxone, fluconazole and filgrastim was initiated. On the second day of hospitalisation, her BP increased to 170/90mm Hg, which was rapidly resolved following clonidine infusion. On the hospital day 4, she exhibited a temperature of 38.9°C, with a significant decrease in the neutrophil count (30 x 109/L). As her general condition was worsening, she was transferred to an isolation room, and blood culture was performed. Subsequently, ceftriaxone was stopped and treatment with amikacin and ceftazidime was started. The fever lasted for only 2 days. After 6 days of admission, her blood test demonstrated platelet count of 10 x 109/L, with decrease in haemoglobin to 7.7 g/dL. Therefore, she received 2 units of RBCs and 1 unit of platelets, and filgrastim dose was increased. Examination for diffuse intravascular coagulation and infection from cytomegalovirus returned negative. On the hospital day 13, after 21 days of the start of capecitabine, she had an episode of severe confusion, psychomotor agitation and self-limited visual hallucination. At that time, she developed severe haematological toxicity manifesting as grade 4 neutropenia, which lasted for 8 days. Subsequent brain CT without contrast and contrast-enhanced brain MRI results were consistent with PRES. Slowly her condition improved and she was discharged on day 20. As she had developed life-t
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