Posterior reversible encephalopathy syndrome (PRES), is a syndrome characterized by headache, confusion, seizures and visual loss, which was first described in 1996 by Judy Hinchey. The cause of PRES is not yet understood. We report a case of a 50-year-old man that developed PRES after the use of mFOLFOX 6 (Oxaliplatin/5-Fluoracil/Leucovorin) chemotherapy for colorectal cancer.

1. PRES, the most uncommon side effect of one of the
commonest chemotherapy regimen, FOLFOX

2. Case Report
PRES, the most uncommon side effect of one of the
commonest chemotherapy regimen, FOLFOX
Viraj Lavingia a,*
, Boman Dhabhar b
, Mudhasir Ahmad a
a
DNB Medical Oncology Fellow; Apollo Hospitals, Jubilee Hills, Hyderabad, India
b
Consultant Medical Oncologist, Fortis Hospital, Mulund, Mumbai, India
a r t i c l e i n f o
Article history:
Received 17 December 2014
Accepted 3 February 2015
Available online xxx
Keywords:
PRES
FOLFOX
Colorectal cancer
a b s t r a c t
Introduction: Posterior reversible encephalopathy syndrome (PRES), is a syndrome charac-
terized by headache, confusion, seizures and visual loss, which was first described in 1996
by Judy Hinchey. The cause of PRES is not yet understood. We report a case of a 50-year-old
man that developed PRES after the use of mFOLFOX 6 (Oxaliplatin/5-Fluoracil/Leucovorin)
chemotherapy for colorectal cancer.
Case report: An adult patient of colorectal cancer underwent resection of the primary tumor
followed by adjuvant chemotherapy with mFOLFOX 6. Five days after the eleventh cycle he
presented with headache and ataxia. A brain MRI (FLAIR/T2) was performed the same day
which showed an increase of signal in both cerebellar lobes. Diagnosis of PRES was made
by the radiologist. His symptoms started to improve after 3 days of hospitalization, and he
was discharged after five days of hospital stay. A repeat MRI after 2 weeks revealed com-
plete resolution of the hyper intense lesions in bilateral cerebellar lobes.
Conclusion: Oncologists must be aware of this uncommon but specific adverse effect of
FOLFOX chemotherapy, as prompt diagnosis may result in complete resolution of PRES.
Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Posterior reversible encephalopathy syndrome (PRES), also
known as reversible posterior leukoencephalopathy syn-
drome (RPLS), is a syndrome characterized by headache,
confusion, seizures and visual loss, which was first described
in 1996 by Judy Hinchey.1
The cause of PRES is not yet un-
derstood. We report a case of a 50-year-old man that devel-
oped PRES after the use of mFOLFOX 6 (Oxaliplatin/5-
Fluoracil/Leucovorin) chemotherapy for colorectal cancer.
2. Case report
A 50-year-old man, non hypertensive, non diabetic, presented
with colorectal adenocarcinoma (T2N1; clinical stage III). He
underwent resection of the primary tumor 6 months before
the admission and he underwent adjuvant chemotherapy
with mFOLFOX 6 (Oxaliplatin/5-fluorouacil/Leucovorin). Five
days after the eleventh cycle he presented with headache and
ataxia. On examination there was left plantar extensor and
cerebellar ataxia. He had no fever or any seizure episodes and
* Corresponding author. Department of Medical Oncology, Apollo Cancer Hospital, Apollo Hospital, Jubilee Hills, Hyderabad 500096,
India. Tel.: þ91 9908711057 (mobile).
E-mail address: drvirajlavingia@gmail.com (V. Lavingia).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1 e3
Please cite this article in press as: Lavingia V, et al., PRES, the most uncommon side effect of one of the commonest chemo-
therapy regimen, FOLFOX, Apollo Medicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.002
http://dx.doi.org/10.1016/j.apme.2015.02.002
0976-0016/Copyright © 2015, Indraprastha Medical Corporation Ltd. All rights reserved.

3. his basic blood tests showed no abnormalities. However he
had mildly raised blood pressure (160/90 mmHg). A brain MRI
(FLAIR/T2) (Fig. 1) was performed the same day which showed
an increase of signal in both cerebellar lobes. Diagnosis of
PRES was made by the radiologist. MR Angio of brain and neck
vessels was normal. 2D-Echocardiogram was normal too. He
was treated with antihypertensive medications and support-
ive care. No antiplatelets or anticoagulants were used. His
symptoms started to improve after 3 days of hospitalization,
and he was discharged after five days of hospital stay. A repeat
MRI (Fig. 2) after 2 weeks revealed complete resolution of the
hyper intense lesions in bilateral cerebellar lobes.
3. Discussion
Posterior reversible encephalopathy syndrome (PRES) was
first described in 1996 by Judy Hinchey.1
The most common
abnormality on neuroimaging is edema involving the white
matter in the posterior portions of the cerebral hemispheres,
especially bilaterally in the parieto-occipital regions. Involve-
ment of additional areas such as the brain stem, cerebellum,
basal ganglia, and frontal lobes, has also been reported.
Common causes include hypertension, renal failure and
certain drugs. No specific drug has shown to be consistently
associated with this adverse effect. We did a literature search
on PUBMED, and there are only 5 cases of PRES associated with
FOLFOX which have been reported.
As shown in Table (Fig. 3), all the five cases had metastatic
disease for which FOLFOX chemotherapy was given, and all
the cases had PRES either in occipital lobes or parieto-occipital
region. This case stands out for two reasons, 1) the site of PRES
and 2) adjuvant nature of the chemotherapy.
Stopping of the offending drug usually results in complete
resolution of PRES. Also re-introduction of the same drug may
Fig. 1 e Bilateral cerebellar hyperintensities.
Fig. 2 e Significant reduction of bilateral cerebellar
hyperintensities.
Fig. 3 e Table depicting all 5 cases so far reported.2e6
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1 e32
Please cite this article in press as: Lavingia V, et al., PRES, the most uncommon side effect of one of the commonest chemo-
therapy regimen, FOLFOX, Apollo Medicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.002

4. lead to recurrence of PRES. In summary, oncologists must be
aware of this uncommon but specific adverse effect of FOLFOX
chemotherapy, as prompt diagnosis may result in complete
resolution of PRES.
Conflicts of interest
All authors have none to declare.
r e f e r e n c e s
1. Hinchey Judy, Chaves Claudia, Appignani Barbara, et al. A
reversible posterior leukoencephalopathy syndrome. N Engl J
Med. 1996;334:494e500.
2. Skelton MR, Goldberg RM, O'Neil BH. A case of oxaliplatin-
related posterior reversible encephalopathy syndrome. Clin
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3. Nagata Y, Omuro Y, Shimoyama T, et al. A case of colon cancer
with reversible posterior leukoencephalopathy syndrome
following 5-FU and oxaliplatin (FOLFOX regime). Gan To Kagaku
Ryoho. 2009 Jul;36:1163e1166.
4. Kim CH, Kim CH, Chung CK, Jahng TA. Unexpected seizure
attack in a patient with spinal metastasis diagnosed as
posterior reversible encephalopathy syndrome. J Korean
Neurosurg Soc. 2011 Jul;50:60e63.
5. Matsunaga M, Miwa K, Araki K, et al. A case of reversible
posterior leukoencephalopathy syndrome (RPLS) induced by
modified FOLFOX. Gan To Kagaku Ryoho. 2012
Aug;39:1283e1286.
6. Porcello Marrone LC, Marrone BF, Pascoal TA, et al. Posterior
reversible encephalopathy syndrome associated with FOLFOX
chemotherapy. Case Rep Oncol Med. 2013;2013:306983.
a p o l l o m e d i c i n e x x x ( 2 0 1 5 ) 1 e3 3
Please cite this article in press as: Lavingia V, et al., PRES, the most uncommon side effect of one of the commonest chemo-
therapy regimen, FOLFOX, Apollo Medicine (2015), http://dx.doi.org/10.1016/j.apme.2015.02.002

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