Letter to the Editor
Posterior reversible leukoencephalopathy after cyanamide overdose
Leucoencefalopatía posterior reversible tras sobredosis de carbimida
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Peñasco, A. González-Castro, J.C. Rodríguez-Borregán, R. Sánchez-de la Torre, A. González-Suárez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Y." "apellidos" => "Peñasco" "email" => array:1 [ 0 => "metalkender@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "González-Castro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.C." "apellidos" => "Rodríguez-Borregán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Sánchez-de la Torre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "González-Suárez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Neurología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leucoencefalopatía posterior reversible tras sobredosis de carbimida" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1669 "Ancho" => 2500 "Tamanyo" => 417092 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">MRI study showing signs of reversible posterior leukoencephalopathy syndrome. Subcortical white matter hyperintensities are observed in both occipital lobes, with focal extension to the left parietal and frontal areas.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Posterior reversible leukoencephalopathy syndrome (PRLS) is characterised by subcortical cerebral oedema of vasogenic origin in patients with acute neurological symptoms.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> We present a case of PRLS associated with cyanamide overdose.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our patient is a 48-year-old woman admitted to the intensive care unit due to low level of consciousness after taking 500<span class="elsevierStyleHsp" style=""></span>mg of Colme® (calcium cyanamide). The patient presented adjustment disorder and was under treatment with cyanamide for alcohol abuse.</p><p id="par0015" class="elsevierStylePara elsevierViewall">At admission we observed somnolence, with the patient opening her eyes when instructed but with no voluntary gaze; menace response absent bilaterally, suggestive of cortical blindness; isochoric and reactive pupils; and nonpersistent horizontal nystagmus. The patient was unable to follow simple instructions, produced unintelligible sounds, and showed loss of strength in the upper limbs with impaired osteomuscular reflexes. The neurological and systemic examination yielded no other relevant findings. An eye fundus examination revealed no alterations. The patient's body weight at the time of admission was 64<span class="elsevierStyleHsp" style=""></span>kg.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Blood analysis showed creatine kinase levels at 2394<span class="elsevierStyleHsp" style=""></span>U/L; aspartate transaminase at 428<span class="elsevierStyleHsp" style=""></span>U/L; alanine aminotransferase at 140<span class="elsevierStyleHsp" style=""></span>U/L; gamma-glutamyl transpeptidase at 240<span class="elsevierStyleHsp" style=""></span>U/L, and bilirrubin at 2<span class="elsevierStyleHsp" style=""></span>mg/dL. The remaining blood analytical values (glucose, urea, creatinine, sodium, potassium, magnesium, phosphorus, calcium, ammonia, C-reactive protein, and lactate), gasometric parameters (pH, pCO<span class="elsevierStyleInf">2</span>, pO<span class="elsevierStyleInf">2</span>, bicarbonate, and base excess), haematology values (haemoglobin, haematocrit, leucocyte, and platelet count), and coagulation parameters (prothrombin activity, prothrombin time, activated partial thromboplastin ratio, and fibrinogen) showed no alterations with regards to our laboratory's reference values. Urine toxicology, including tests for amphetamines, cocaine, tetrahydrocannabinol, barbiturates, benzodiazepines, tricyclic antidepressants, opioids, and phencyclidine, showed negative results.</p><p id="par0025" class="elsevierStylePara elsevierViewall">A head computed tomography (CT) scan showed occipital white matter hypodensity bilaterally, predominantly affecting the left side. An electroencephalography showed signs of moderate encephalopathy with no signs of epileptiform activity. MRI findings confirmed the presence of vasogenic oedema associated with PRLS, involving both occipital lobes with focal extension to the parietal and left frontal areas (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">We administered activated charcoal, suspended cyanamide, and continued with life support measures. The patient progressed favourably, fully recovering after 14 days. Blood analysis and electroencephalography findings also normalised. Furthermore, the follow-up MRI scan confirmed the disappearance of the alterations observed at admission. The patient subsequently admitted she had taken calcium cyanamide with suicidal intent and denied having consumed alcohol concomitantly.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Carbimide or calcium cyanamide is used for treating alcoholism as it causes aversion to alcohol by provoking aldehyde syndrome or the Antabuse effect.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,3</span></a> In the absence of alcohol consumption, cyanamide is well tolerated at normal doses. Although few cases are described in the literature, overdose in the absence of alcohol consumption has been associated with kidney failure, liver failure, respiratory failure, decreased level of consciousness, and metabolic acidosis.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,3</span></a> In our case, symptoms manifested after ingestion of cyanamide and no other associated factor could be identified. Furthermore, the patient explicitly denied having consumed alcohol concomitantly.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Our patient presented acute neurological impairment consisting of encephalopathy associated with cortical blindness. The first CT scan was decisive in the diagnosis, whereas the blood analysis findings did not explain the neurological symptoms. The early MRI study enabled us to establish the diagnosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">PRLS is characterised by subcortical vasogenic oedema in patients presenting acute neurological alterations.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4,5</span></a> Encephalopathy presents the typical symptoms, from disorientation to deep coma. Other reported symptoms are seizures, visual alterations, and headache. Focal symptoms and signs of spinal cord involvement may manifest less frequently.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Early diagnosis of the syndrome is difficult, especially in emergency situations. However, PRLS should be suspected in cases in which neurological signs and the clinical context are compatible. Imaging studies are essential for establishing an appropriate diagnostic approach. Although some radiological signs of vasogenic cerebral oedema may be observed on CT images, MRI studies better identify this type of lesion.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Causes associated with PRLS to date include acute changes in blood pressure, acute kidney failure, autoimmune diseases, eclampsia and preeclampsia, sepsis, and administration of certain drugs.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4,5</span></a> In the case of this patient, we did not identify any factor previously associated with this disease.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Prognosis is generally favourable. Between 75% and 90% of patients achieve full recovery during the first weeks. Sequelae reported in the literature include intracranial haemorrhage, hydrocephalus, and intracranial hypertension.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Fatal cases directly associated with the condition have also been described.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Diagnosis of PRLS is based on clinical and radiological findings and a compatible clinical context. Therefore, describing all situations associated with this entity may help establish an early diagnosis in future.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Peñasco Y, González-Castro A, Rodríguez-Borregán JC, Sánchez-de la Torre R, González-Suárez A. Leucoencefalopatía posterior reversible tras sobredosis de carbimida. Neurología. 2020;35:67–68.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1669 "Ancho" => 2500 "Tamanyo" => 417092 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">MRI study showing signs of reversible posterior leukoencephalopathy syndrome. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 0 | 6 |
| 2024 October | 12 | 8 | 20 |
| 2024 September | 27 | 4 | 31 |
| 2024 August | 16 | 3 | 19 |
| 2024 July | 11 | 5 | 16 |
| 2024 June | 16 | 3 | 19 |
| 2024 May | 19 | 1 | 20 |
| 2024 April | 17 | 10 | 27 |
| 2024 March | 18 | 3 | 21 |
| 2024 February | 14 | 2 | 16 |
| 2024 January | 11 | 3 | 14 |
| 2023 December | 18 | 5 | 23 |
| 2023 November | 14 | 6 | 20 |
| 2023 October | 24 | 10 | 34 |
| 2023 September | 10 | 0 | 10 |
| 2023 August | 17 | 8 | 25 |
| 2023 July | 11 | 6 | 17 |
| 2023 June | 12 | 4 | 16 |
| 2023 May | 33 | 6 | 39 |
| 2023 April | 32 | 0 | 32 |
| 2023 March | 31 | 7 | 38 |
| 2023 February | 17 | 3 | 20 |
| 2023 January | 8 | 4 | 12 |
| 2022 December | 17 | 3 | 20 |
| 2022 November | 19 | 8 | 27 |
| 2022 October | 24 | 5 | 29 |
| 2022 September | 15 | 6 | 21 |
| 2022 August | 18 | 5 | 23 |
| 2022 July | 9 | 8 | 17 |
| 2022 June | 8 | 12 | 20 |
| 2022 May | 15 | 7 | 22 |
| 2022 April | 11 | 6 | 17 |
| 2022 March | 12 | 7 | 19 |
| 2022 February | 30 | 5 | 35 |
| 2022 January | 62 | 6 | 68 |
| 2021 December | 38 | 7 | 45 |
| 2021 November | 28 | 6 | 34 |
| 2021 October | 41 | 12 | 53 |
| 2021 September | 47 | 9 | 56 |
| 2021 August | 47 | 5 | 52 |
| 2021 July | 8 | 7 | 15 |
| 2021 June | 12 | 6 | 18 |
| 2021 May | 24 | 10 | 34 |
| 2021 April | 61 | 27 | 88 |
| 2021 March | 15 | 11 | 26 |
| 2021 February | 30 | 9 | 39 |
| 2021 January | 23 | 14 | 37 |
| 2020 December | 29 | 9 | 38 |
| 2020 November | 23 | 8 | 31 |
| 2020 October | 9 | 7 | 16 |
| 2020 September | 8 | 8 | 16 |
| 2020 August | 12 | 17 | 29 |
| 2020 July | 16 | 10 | 26 |
| 2020 June | 6 | 3 | 9 |
| 2020 May | 9 | 8 | 17 |
| 2020 April | 10 | 8 | 18 |
| 2020 March | 0 | 1 | 1 |
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