Correct!
5. All of the above
National Cancer Institute toxicity grading for encephalopathy spans Grade 1 (no encephalopathy symptoms), Grade 2: mild signs and symptoms, no interference with activities of daily living, Grade 3: signs or symptoms that interfere with activities of daily living, with hospitalization indicated, Grade 4: life-threatening and/or disabling signs and symptoms, Grade 5: death (3).
Most patients do not require specific treatment for IIE and the encephalopathy improves spontaneously. Although serious, long-term outcomes of encephalopathy are rare, they can include organic brain damage, coma, and death. Some reports suggest that methylene blue, dexmedetomidine, or thiamine may be useful for the treatment and/or prevention of IIE (4). The most benefit is seen in patients with Grade III or higher toxicity.
The patient’s chemotherapy is held and she is started on methylene blue. A few hours later, she is found unresponsive in her room. She has marked tachypnea and increased work of breathing. She is newly tremulous and shaking diffusely, and is very restless. Labs again are unchanged. ABG reveals respiratory alkalosis. CXR is stable and CT head is without acute abnormality. On exam however, she is mildly febrile at 38oC, tachycardic to 164, tachypneic to 56, and appears ill. She has dilated pupils, and neurological exam reveals a Glasgow Coma Score of 5, and 3+ reflexes in biceps, brachioradialis, and patellar tendons bilaterally. She has sustained clonus at the ankles bilaterally.
What is the most likely diagnosis for her current presentation? (Click on the correct answer to proceed to the fourth of five pages)