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.
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.