A seldom-encountered complication has emerged in the treatment of Chronic Myeloid Leukemia (CML) with the tyrosine kinase inhibitor, Nilotinib. The journal “Rinsho Ketsueki – The Japanese Journal of Clinical Hematology” detailed an incident involving a 50-year-old female patient who developed Posterior Reversible Encephalopathy Syndrome (PRES) after approximately two years of receiving Nilotinib as her initial treatment for CML. The case, now published under DOI: 10.11406/rinketsu.64.1514, represents the first known instance where PRES is linked to Nilotinib therapy.
Clinical Presentation
The patient, under the care of Dr. Daisuke Kudo and colleagues at the Tokyo-Kita Medical Center, presented with a significant constellation of symptoms including headache, blurred vision, impaired consciousness, and marked hypertension – classic clinical features associated with PRES.
Posterior reversible encephalopathy syndrome is a neurological disorder that can be caused by a variety of factors, often associated with sudden changes in blood pressure that leads to the disruption of the blood-brain barrier. The resulting vasogenic edema is evidenced by symptoms relating to neurologic impairments and visual disturbances.
Diagnosis and Management
Medical imaging and symptoms led to the diagnosis of PRES. Swift action was taken to ameliorate the condition; Nilotinib was temporarily ceased, and the patient was initiated on antihypertensive therapy while under ventilator management to support her breathing due to her impaired consciousness. Fortunately, her symptoms resolved quickly following the interventions, consistent with the reversible nature of the syndrome when promptly addressed.
Mechanism of PRES with Nilotinib
The onset of PRES in the context of Nilotinib therapy, as discussed in this case report, raises questions about the mechanism at play. Dr. Kudo’s team hypothesized that systemic arterial hypertension, which is sometimes induced by Nilotinib, combined with direct endothelial injury could disrupt the blood-brain barrier, precipitating the condition. This episode underscores the need for clinical vigilance when administering tyrosine kinase inhibitors such as Nilotinib, due to their potential for vascular adverse events.
Literature Review and Discussion
Previous studies have reported PRES with the usage of some other tyrosine kinase inhibitors; however, this is the inaugural report implicating Nilotinib in such an event. Healthcare professionals already recognize the need for monitoring blood pressure and other potential cardiovascular complications during Nilotinib treatment. Given the significant morbidity associated with PRES, this report emphasizes the importance of prompt identification and treatment of hypertension and related endothelial dysfunctions in patients receiving Nilotinib.
Implications for Clinical Practice
While PRES is generally reversible, it necessitates immediate medical attention. This case prompts a greater awareness of the importance of regular monitoring of patients on Nilotinib, not only for the typical hematological responses but also for neurological symptoms and hypertension that could herald the development of PRES.
Dr. Suzuki Hiroshi and his team concluded that a multidisciplinary approach is critical when treating patients with CML on Nilotinib, particularly in collaboration with neurologists to promptly identify and manage any complications akin to PRES.
Keywords
1. Chronic Myeloid Leukemia treatment
2. Nilotinib and PRES
3. Tyrosine Kinase Inhibitors complications
4. Posterior Reversible Encephalopathy Syndrome
5. Vascular adverse events in leukemia therapy
References
1. Kudo, D., Suzuki, H., Abe, N., Hirai, R., Tanimura, A., Takeshita, M., & Miwa, A. (2023). [Posterior reversible encephalopathy syndrome during nilotinib treatment for chronic myeloid leukemia]. Rinsho Ketsueki – The Japanese Journal of Clinical Hematology, 64(12), 1514-1518. DOI: 10.11406/rinketsu.64.1514.
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