Our patient was a 71 year old woman diagnosed with a high-grade right triceps pleomorphic sarcoma in 2017, which was resected with a wide local excision and treated with adjuvant radiation. A surveillance computed tomography (CT) scan of the thorax showed metastases to the lung and mediastinum in September 2018 and she was treated with 6 cycles of doxorubicin. Progression of disease identified in January 2019 necessitated a change of treatment to ifosfamide and mesna, and she was admitted for each cycle. Re-staging CT scan after 2 cycles demonstrated an interval decrease in the size and number of the multiple pulmonary nodules with one nodule reducing in size from 18 mm down to 6 mm, complete resolution of a 15 mm right para-oesophageal node and no new disease identified.\nPast medical history included hypertension, hysterectomy for menorrhagia and appendectomy. Her medications on admission were lercanidipine, losartan, hydrochlorothiazide, potassium supplement, enoxaparin (thrombosis prophylaxis), senna, domperidone, aprepitant, Fortisip Compact Fibre, Procal Shot, multivitamin and evening primrose oil (not administered due to unknown possible drug interactions). She was known to develop a rash with penicillin but had no other allergies.\nExamination on admission for cycle 3 was remarkable for oral candidiasis. Routine blood investigations identified potassium 2.7 mmol/l which was replaced with IV and oral potassium and albumin of 32 g/l. She developed nausea after day 2 and had one episode of vomiting.\nOn day 3, she was noted to be resting during the morning, however was easily rousable and able to stay awake. Chemotherapy was commenced at midday. Within 4 h, it was noted that she was difficult to rouse. Vital signs were within normal ranges. A blood gas confirmed a potassium of 2.7 mmol/l, but no other abnormality was identified and the pH was uncompensated and in the normal range. An ECG was unremarkable. It was hypothesized that she had developed ifosfamide encephalopathy and an EEG was obtained.
A 75-year-old woman was diagnosed with a pleiomorphic rhabdomyosarcoma (FNCLCC grade III) of the left thigh. She underwent a tumor resection in April 2010 followed by local irradiation. Bilateral pulmonary metastases were evidenced on CT scan in July 2011. Six cycles of doxorubicin (60 mg/m2 every 3 weeks) were given before the resection of the left metastasis in December 2011 and of the right one in February 2012. Because of tumor invasion of the left pleura, the patient received 3 cycles of IFO (2 g/m2/day for 5 days every 3 weeks) with aprepitant (80 mg/day × 5 days) and steroids. Eight days after the 3rd cycle of IFO, the patient was admitted for sepsis, lung infection, pancytopenia (1,400 leukocytes, 1,200 neutrophils, hemoglobin 8.2 g/dl, and 13,000 platelets) and renal insufficiency (620 µM creatinine). She presented vigilance disorders and confusion (Glasgow score 13). No abnormality or hemorrhage was detected on cerebral CT. MRI was judged nonfeasible. Lumbar puncture showed neither signs of infection nor presence of tumor cells. Methylene blue was ineffective. Despite restoration of normal blood count and normal renal function after one session of hemodialysis, the coma worsened leading to death.