RESUMEN
A 74-year-old woman with a diffuse large B-cell lymphoma was treated with rituximab and CHOP chemotherapy. After three cycles of chemotherapy she developed progressive symptoms of motor imbalance, fatigue, weight loss and impaired cognitive function, which was interpreted as toxicity of the CHOP chemotherapy. The sixth cycle CHOP chemotherapy was withheld and three additional cycles of rituximab were given. Two weeks later, neurological symptoms appeared, including abducens nerve palsy of her left eye, ataxia and hemiparesis of her right body. MRI of the brain revealed two hyperintense lesions on T2-weighted and fluid-attenuated inversion recovery images without oedema or gadolinium enhancement. A PCR on John Cunningham (JC) virus DNA in cerebrospinal fluid was negative, but subsequent brain biopsy diagnosed progressive multifocal leukoencephalopathy (PML). She rapidly deteriorated and died. Awareness of PML during immunosuppressive therapy can be lifesaving, since only immune reconstitution can prevent mortality in these patients.
Asunto(s)
Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Encéfalo/patología , Inmunosupresores/efectos adversos , Leucoencefalopatía Multifocal Progresiva/etiología , Leucoencefalopatía Multifocal Progresiva/patología , Linfoma de Células B Grandes Difuso/tratamiento farmacológico , Anciano , Anticuerpos Monoclonales de Origen Murino/efectos adversos , Biopsia , Ciclofosfamida/efectos adversos , Doxorrubicina/efectos adversos , Femenino , Humanos , Prednisona/efectos adversos , Rituximab , Vincristina/efectos adversosRESUMEN
OBJECTIVE: Current prognosticators for patients with subarachnoid hemorrhage (SAH) do not take into account signs of extracerebral organ dysfunction. This may explain the only moderate predictive value of these prognosticators. We assessed the prognostic value of the simplified acute physiology score (SAPS) II in SAH patients. METHODS: In a retrospective cohort study of 148 consecutive SAH patients, we related the SAPS II calculated within 24 hours after admission to clinical and initial computed tomographic imaging characteristics using the Mann-Whitney U test. We compared the prognostic value of the SAPS II with that of the World Federation of Neurosurgical Surgeons score, the patient's age, and the amount of blood showing in computed tomographic imaging for the occurrence of delayed cerebral ischemia using Cox proportional hazards modeling or, for poor outcome (death or dependence), logistic regression modeling. RESULTS: In the univariate analysis, the SAPS II was the strongest prognosticator; in the multivariate model, the SAPS II was the only independent predictor for outcome (odds ratio, 1.08; 95% confidence interval, 1.06-1.11]). Patients in the highest tertile of SAPS II had a significantly higher risk of poor outcome than those in the lowest tertile (odds ratio, 30.9; 95% confidence interval, 9.9-96.7]). The SAPS II was also the only independent predictor for the occurrence of delayed cerebral ischemia (hazard ratio, 1.020; 95% confidence interval, 1.002-1.039]). CONCLUSION: The SAPS II is a useful and reliable prognosticator in SAH patients. This score may provide more information than specific SAH scales in predicting poor outcome or the occurrence of delayed cerebral ischemia in some circumstances.