A 25-year-old male patient diagnosed as a case of Philadelphia chromosome-negative B-cell acute lymphoblastic lymphoma (ALL) and who had relapsed after receiving the Berlin-Frankfurt-Münster 90 acute lymphoblastic leukemia protocol (BFM ALL protocol) was started on MINE protocol (injection ifosfamide 4 g/m2 was divided over 3 days [day 1–3] and administered IV over a 1 h period, injection mitoxantrone 8 mg/m2 [day 1] administered as a short IV infusion, injection etoposide 65 mg/m2/day [day 1–3] was infused over 1 h, and injection mesna 1330 mg/m2 [days 1–3]) after the patient had progressed on DHAP regimen (injection cisplatin 100 mg/m2 [day 1], high-dose cytarabine 2 g/m2 twice a day [day 2], and tablet prednisolone 40 mg/day [day 2–4]). After 24 h of the 1st day of chemotherapy, the patient started developing headache, vomiting which was followed in couple of hours by disoriented behavior, and one episode of seizure. In view of above complaints, patient chemotherapy was withheld as the patient developed headache and vomiting. For the above complaints, patient's all routine investigations such as complete blood count, renal function, and liver function test were performed along with albumin and electrolytes. All the investigations were within normal limits. Electrocardiogram was done which was within normal limits. Magnetic resonance imaging of brain was obtained which did not show any abnormality. Considering the above case scenario and ruling out the possible causes of acute delirious state such as electrolyte abnormalities and intracranial bleed, we entertained the possibility of IIE. The patient was started on hydration therapy with IV fluids and dextrose normal saline infusion at the rate of 100 ml/m2 followed by which injection methylene blue was procured and started at the dose of 50 mg (1% aqueous solution) IV over 5 min, six times daily, and antiemetics such as ondansetron 4 mg by needle were administered twice a day for initial 3 days and then whenever needed. Within a period of 24 h, the patient started improving in the form of decrease in vomiting and response to oral commands. Later complete recovery occurred within 48–72 h. Till then injection methylene blue and hydration were continued. Furthermore, the patient was given IV 5% albumin.\nHence, the patient who had presented with above-mentioned complaints with normal imaging and blood investigations and who had responded to methylene blue confirmed our diagnosis of the IIE. Furthermore, retrospectively, we looked over the factors that precipitated the IIE. Albumin, renal and liver function, and electrolytes were well within normal limits at the start of infusion of ifosfamide. However, the patient had received injection fosaprepitant before the start of injection ifosfamide.\nWe then reviewed the literature, and it confirmed that the precipitating factor for IIE was none other than aprepitant.
This is a 13-year-old boy with no pathological history, hospitalized in the\nhematology-oncology department for abdominal rhabdomyosarcoma. The history of the disease\ngoes back to 3 months of his hospitalization by the installation of abdominal pains with\nprogressive deterioration of the general condition. On admission, the patient was conscious\nwith a GCS score 15/15, apyretic with impaired general condition, weight = 30 kg. Physical\nexamination revealed a large papable abdominal mass extending from the epigastric to the\nright hypochondrium. Ultrasound then abdomino-pelvic Computed tomography (CT) scan confirmed\nthe diagnosis by objectifying a median retro-peritoneum mass. The biological assessment was\nnormal. An ultrasound-guided biopsy was performed. The histological diagnosis was in favor\nof an undifferentiated sarcoma. Extension workup revealed lung micronodules and peritoneal\nnodules under the liver. The child was put on anti-cancer treatment combining\nifosfamide-vincristine-actinomycin (IVA) and MesnaR to prevent urological\ntoxicity. The dosages of these molecules were: Ifosfamide (3 g/m2/day) 3 g/day as\nan infusion administered over 3 hours, vincristine (1.5 mg/m2/day) 1.5 mg by slow\ndirect intravenous injection, actinomycine (1.5 mg/m2/day) 1.5 mg as a slow\ndirect intravenous injection and MesnaR at a dose of 900 mg/day. Ten days after\ntreatment, the child developed seizures. An emergency computed tomography was performed\nshowing hypo-dense right frontal brain lesions (). There was no sensory or motor deficit. To\nbetter characterize, we performed a cerebral magnetic resonance imaging (MRI) which\nobjectified the subcortical lesions in T2 and FLAIR hyper signal, in T1 hypo signal, without\nrestriction of the diffusion sequence and without enhancement after injection of gadolinium\n(). Knowing the side\neffect of ifosfamide, the IVA-based protocol was stopped and modified by the\nVincristine-Actinomycin-Cyclophosphamide (VAC) protocol. The evolution was marked by the\ndefinitive cessation of seizures without other signs. No biological abnormality was detected\nand no specific treatment was added outside of the new protocol. Two weeks after stopping\nifosfamide, we performed a control brain MRI which revealed that the previously described\nbrain lesions had disappeared (). Faced with the favorable clinical course and the disappearance of the brain\nlesions, the diagnosis of IIE was retained.