Encefalopatía secundaria a intoxicación por lamotrigina

Sr. Editor: La ingesta voluntaria de medicamentos con fines autolíticos es un acto más frecuente en pacientes epilépticos o con trastornos psiquiátricos. Los fármacos pautados para dichas enfermedades se convierten así en sustancias susceptibles de causar intoxicación..

Encefalopatía posterior reversible asociada a combinación con pembrolizumab

Sr. Editor: El síndrome de encefalopatía posterior reversible (PRES) se caracteriza por hallazgos clínicos y radiológicos, generalmente recuperables, debidos a edema vasogénico. Sin criterios diagnósticos establecidos, es una patología infradiagnosticada sobre la que debemos estar alerta ante un contexto propicio1. Puede tener un inicio agudo o subagudo y mayoritariamente progresivo, siendo lo más habitual la afectación del nivel de conciencia, las alteraciones visuales y las crisis epilépticas. Su asociación con hipertensión arterial aguda es muy frecuente y guarda relación con su fisiopatología. El pronóstico viene marcado principalmente por sus posibles causas, como cuadros autoinmunes, sepsis, eclampsia y diversas sustancias citotóxicas1. La inmunoterapia, cada vez más usada en diferentes tipos de cáncer, es uno de los factores predisponentes. Estos inhibidores de puntos de control inmunitario (ICI) se han asociado a distintos efectos adversos neurológicos secundarios a la regulación de las células T2. Presentamos un caso de PRES tras tratamiento con pembrolizumab, evidenciado por cefalea, disminución de conciencia y ceguera cortical, con síndrome de Anton asociado..

Diagnostic delay and outcome in immunocompetent patients with primary central nervous system lymphoma in Spain: a multicentric study

GELTAMO and GENOSEN group.[Introduction] To assess the management of immunocompetent patients with primary central nervous system lymphomas (PCNSL) in Spain.[Methods] Retrospective analysis of 327 immunocompetent patients with histologically confirmed PCNSL diagnosed between 2005 and 2014 in 27 Spanish hospitals.[Results] Median age was 64 years (range: 19–84; 33% ≥ 70 years), 54% were men, and 59% had a performance status (PS) ≥ 2 at diagnosis. Median delay to diagnosis was 47 days (IQR 24–81). Diagnostic delay > 47 days was associated with PS ≥ 2 (OR 1.99; 95% CI 1.13–3.50; p = 0.016) and treatment with corticosteroids (OR 2.47; 95% CI 1.14–5.40; p = 0.023), and it did not improve over the years. Patients treated with corticosteroids (62%) had a higher risk of additional biopsies (11.7% vs 4.0%, p = 0.04) but corticosteroids withdrawal before surgery did not reduce this risk and increased the diagnostic delay (64 vs 40 days, p = 0.04). Median overall survival (OS) was 8.9 months [95% CI 5.9–11.7] for the whole series, including 52 (16%) patients that were not treated, and 14.1 months (95%CI 7.7–20.5) for the 240 (73.4%) patients that received high-dose methotrexate (HD-MTX)-based chemotherapy. Median OS was shorter in patients ≥ 70 years (4.1 vs. 13.4 months; p < 0.0001). Multivariate analysis identified age ≥ 65 years, PS ≥ 2, no treatment, and cognitive/psychiatric symptoms at diagnosis as independent predictors of short survival.[Conclusions] Corticosteroids withdrawal before surgery does not decrease the risk of a negative biopsy but delays diagnosis. In this community-based study, only 73.4% of patients could receive HD-MTX-based chemotherapy and OS remains poor, particularly in elderly patients ≥ 70 years.This work was partially supported by Grant PI1501303 from ISCIII and Fondo Europeo de Desarrollo Regional (FEDER)