Sunitinib
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Sunitinib Worsening of hypertension leading to posterior reversible encephalopathy syndrome: case report
A 76-year-old woman developed worsening of hypertension leading to posterior reversible encephalopathy syndrome (PRES) during treatment with sunitinib for a gastrointestinal stromal tumour (GIST). The woman, who had chronic hypertension well-controlled on irbesartan/hydrochlorothiazide, was subsequently diagnosed with GIST. Thereafter, she underwent surgery, followed by imatinib therapy. However, disease progression became evident after about 1.5 years; hence, imatinib was discontinued and replaced with sunitinib 50mg daily [route not stated]. Two weeks later, following completion of the first cycle of sunitinib, she started exhibiting fluctuating BP (~200/90mm Hg), associated with weight loss and nausea. Therefore, the woman’s antihypertensive therapy was enhanced with ramipril during sunitinib cycles. However, after 2 months, she was hospitalised due to generalised tonic-clonic seizures. She received diazepam, resulting in prompt resolution of seizures. Subsequent blood tests, including LDH, serum sodium, calcium, magnesium, creatinine and albumin, were found to be normal, apart from slight leucopenia and thrombocytopenia [aetiology not specified]. On neurologic examination, she appeared to be drowsy, with optic ataxia, reduced visual acuity and right upper limb weakness. She started receiving levetiracetam; during this time, she experienced no further seizures. During the initial days, her neurological status did not improve even though her BP gradually reduced with clonidine and antihypertensive therapy. Brain MRI, including ADC map, taken on the day after clinical onset revealed a dominant parieto-occipital pattern with increased and confluent regions of hyperintensity in T2-weighted and fluidattenuated inversion recovery (FLAIR) sequences in subcortical temporo-parietooccipital regions bilaterally. Based on her medical history and the clinical/neuroradiological findings, she was diagnosed with PRES. Sunitinib-related worsening of hypertension was believed to be the main causative factor for PRES. Therefore, sunitinib was withheld, while levetiracetam was slowly tapered and stopped due to worsening thrombocytopenia [aetiology not specified]. She experienced no further seizures after levetiracetam cessation. A repeat brain MRI after 10 days showed improvement in radiological abnormalities. Her consciousness recovered within 3 days; the right limb paresis resolved in 2 weeks, and her optic ataxia and visual acuity progressively improved over the subsequent 3 weeks. During 2-month follow-up, her neurological examination was found to be normal, with recovery of functions in activities of daily living. Also, brain MRI revealed further regression of the abnormalities, although gliotic-like alterations were visualised. Thereafter, she started receiving imatinib, with no neurological complications. Rifino N, et al. Sunitinib associated posterior reversible encephalopathy syndrome in a patient treated for GIST
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