A 64-year-old male smoker and regular drinker was diagnosed with moderately differentiated sigmoid adenocarcinoma.
It was decided to start adjuvant chemotherapy (CT) (FULFOX-6 m scheme).
The patient's initial laboratory test was normal and received the first cycle of chemotherapy at the following doses: oxaliplatin 136 mg (85 mg/m2); folinic 640 mg (400 mg/m2); 5-FU 640
Forty-eight hours after the beginning of the cycle, the patient was admitted to the emergency room due to disorientation and vomiting. The patient was diagnosed with deterioration of renal function secondary to vomiting, which improved after rehydration treatment.
Fifteen days later, after presenting normal laboratory findings (except slightly increased neutrophil and GPT values), she received the second cycle of chemotherapy at the same doses.
At 24 hours she was admitted to the emergency room due to disorientation, psychomotor agitation and decreased level of consciousness.
The patient had experienced profuse sweating at home but not vomiting, nausea or other toxicities.
Analytical analysis revealed marked increases in urea 81 mg/dl (10-50 mg/dl), lactate 7.09 mmol/L (0-1.8 mmol/L) and GL (0-59 mmol/L (0-351) micromol/L).
Concomitant infection was ruled out and neurological examination revealed disorientation in space and time, aphasia, no response to orders and old right hemiparesis.
Acute ischemia, cerebrospinal fluid abnormalities and electroencephalogram were ruled out and were compatible with hepatic or metabolic encephalopathy.
Initial treatment with chemotherapy was established, and paromomycin was discontinued.
The patient improved two days after the start of treatment, recovering the level of consciousness and was able to maintain a coherent conversation.
Four days later there were no signs of encephalopathy and laboratory parameters returned to normal.
The final diagnosis after excluding other possible causes was Grade IV encephalopathy in a patient with chronic liver disease due to alcohol consumption triggered by 5-FU.
As for cancer treatment, it was decided to suspend adjuvant chemotherapy and periodic reviews were initiated.
