Ifosfamide induced encephalopathy in a child with osteosarcoma

BACKGROUND

Ifosfamide (IFO) is an alkylating agent used to treat broad range of malignancies. One of the life-threatening toxic effects is reversible neurotoxicity. In this report; we presented a case report of ifosfamide induced encephalopathy (IIE) in a child with osteosarcoma in order to emphize that it is important to continue ifosfamide treatment as well as the importance of this potentially fatal complication.

CASE REPORT

Following the 20th week of ifosfamide treatment, the patient's follow-up with the diagnosis of osteosarcoma developed neurological findings. Laboratory analyzes before and after ifosfamide infusion were normal. No pathological findings were seen on MR imaging. Hypoglycemia, electrolyte disturbances, encephalitis, meningitis, metastasis and posterior reversible encephalopathy syndrome (PRES) were not considered. Electroencephalography was found compatible with neuronal hyperexcitability originating from the left hemisphere. With the diagnosis of ifosfamide induced encephalopathy, prophylaxis with methylene blue was received before the next infusion of ifosfamide. Neurological findings were not observed in the patient's follow-up.

CONCLUSION

Patients who develop IIE can continue their treatment protocol with methylene blue prophylaxis and supportive therapy.

Neurotoxicity of antineoplastic drugs: Mechanisms, susceptibility, and neuroprotective strategies

This review summarizes the adverse effects on the central and/or peripheral nervous systems that may occur in response to antineoplastic drugs. In particular, we describe the neurotoxic side effects of the most commonly used drugs, such as platinum compounds, doxorubicin, ifosfamide, 5-fluorouracil, vinca alkaloids, taxanes, methotrexate, bortezomib and thalidomide. Neurotoxicity may result from direct action of compounds on the nervous system or from metabolic alterations produced indirectly by these drugs, and either the central nervous system or the peripheral nervous system, or both, may be affected. The incidence and severity of neurotoxicity are principally related to the dose, to the duration of treatment, and to the dose intensity, though other factors, such as age, concurrent pathologies, and genetic predisposition may enhance the occurrence of side effects. To avoid or reduce the onset and severity of these neurotoxic effects, the use of neuroprotective compounds and/or strategies may be helpful, thereby enhancing the therapeutic effectiveness of antineoplastic drug.

Hydration, methylene blue, and thiamine as a prevention regimen for ifosfamide-induced encephalopathy

Ifosfamide is an alkylating chemotherapeutic agent used in the treatment of many malignancies. Ifosfamide-induced encephalopathy is one potential side effect that represents a major drawback to ifosfamide therapy and often necessitates discontinuation of chemotherapy. Previous reports demonstrate moderate effectiveness of prophylactic methylene blue at thwarting ifosfamide-induced encephalopathy. This is a report of a 64-year-old female with relapsed double-hit diffuse large B-cell lymphoma who developed severe altered mental status and neurological symptoms after receiving a second dose of ifosfamide as part of her salvage standard dose R-IE (rituximab, ifosfamide, etoposide), in preparation for chimeric antigen receptor T-cell therapy. Ifosfamide was stopped and extensive metabolic and infectious workups, in addition to brain images, were all unremarkable. Her symptoms were attributed to ifosfamide. Prior to initiating cycle 2 of R-IE, she was started on prophylactic oral thiamine 100 mg, once a day, one week prior to her admission, methylene blue 50 mg intravenous every 6 h (for a total of four doses) and intravenous hydration with normal saline starting on day one of admission. Ifosfamide was administered in the standard dose 2000 mg/m², days 1-3 as continuous intravenous infusion over 24 h. She tolerated the first two days of ifosfamide well and only developed mild encephalopathy during her last dose of ifosfamide. Her symptoms resolved completely without any intervention the following day and she completed all scheduled doses. She eventually received chimeric antigen receptor T-cell therapy. Our report demonstrates the use of hydration, methylene blue, and thiamine as a successful secondary prevention regimen for ifosfamide-induced encephalopathy.

Complications from pharmacotherapy

The pharmacotherapy management of cancers of the nervous system has significant overlap with systemic solid cancers that may utilize similar drugs or agents. There is however a unique aspect related to central nervous system (CNS) cancers where therapies directed against a malignant process may have enhanced toxicities or toxicities unique to the CNS. In addition, many agents used to treat CNS malignancies have unique CNS toxicities that may require a specific intervention. This chapter attempts to review conventional and biologic therapies utilized for CNS malignancies and characterize expected and, if known, unique toxicities.

Effectiveness of Vestibular Rehabilitation in Hemodialysis Patients With Dizziness

PURPOSE

This study evaluated the effectiveness of vestibular rehabilitation (VR) for hemodialysis (HD) patients with chronic dizziness.

DESIGN

A single-blind, randomized controlled study was performed.

METHODS

Cluster-randomized sampling was used to select the experimental group from two outpatient dialysis clinics. A total of 26 patients participated in the study. Dizziness Handicap Inventory (DHI) and falls were used as outcome measures. Data were collected at baseline (T1), 3 months (T2), and 6 months (T3).

FINDINGS

Two-way repeated-measures ANOVA of DHI revealed a statistically significant group and time interaction. Dizziness handicap outcome was significantly reduced over time in the experimental group (DHI total score, T1 = 35.29, T2 = 32.86, T3 = 27.86, p = .001).

CONCLUSIONS

VR exercise instructed by nurses can be effective in alleviating handicap imposed by dizziness in dialysis patients.

CLINICAL RELEVANCE

Nurses are encouraged to learn VR as a simple exercise to improve well-being in dialysis patients with chronic dizziness.