A 47-year-old African American male with stage III cutaneous T-cell lymphoma with large cell transformation presented to the hospital with shortness of breath, fatigue, and failure to thrive. The patient had progressed through multiple lines of chemotherapy including EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin), romidepsin, gemcitabine, brentuximab, and pralatrexate. At inpatient presentation, he had malignant pleural effusions, hypercalcemia, and leukocytosis with eosinophilia. Given the patient’s rapidly worsening clinical course, it was decided to start ifosfamide, carboplatin, and etoposide (ICE) chemotherapy with etoposide 100 mg/m2 on days 1 to 3, ifosfamide 5000 mg/ on day 2 infused over 24 hours, and carboplatin with an area under curve (AUC) of 5 on day 3. He was alert and oriented prior to and during the infusion but became delirious on day 3 of the regimen, 6 hours after the completion of the ifosfamide infusion. Physical examination did not reveal any stereotypical movements or twitching. His mental status worsened from initial agitation and confusion to drowsiness and eventually stupor. Diagnostic evaluation for acute mental status change including complete blood count, comprehensive metabolic panel, ammonia level, and computed tomography scan of the head was negative. Infectious workup including blood cultures, urine culture, and chest X-ray did not reveal any infectious process contributing to the altered mental status. Thus, the patient’s acute altered mental status was attributed to IME. He was started on hydration, and 50 mg of intravenous MB was given every 4 hours. His mental status began to improve 16 hours after start of MB and was back to his baseline after 48 hours of treatment (received 12 total doses). The one cycle of ICE chemotherapy temporarily improved his disease but due to neurotoxicity, he was not rechallenged.
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.