Gemcitabine-associated Posterior Reversible Encephalopathy Syndrome in a Patient with Metastatic Cervical Cancer: A Rare and Fatal Presentation

A BSTRACT Posterior reversible encephalopathy syndrome (PRES) is an uncommon but potentially serious neurotoxic complication characterized by acute neurological symptoms and characteristic radiological findings. Although it is classically associated with hypertension, renal failure, and immunosuppressive therapy, PRES has also been reported in association with cytotoxic chemotherapy, including gemcitabine. Gemcitabine-associated PRES remains rare, particularly in normotensive patients and in the presence of concurrent central nervous system malignancy. We report the case of a 39-year-old woman with metastatic HPV-positive cervical squamous cell carcinoma who developed acute neurological deterioration after receiving gemcitabine and carboplatin. She presented with severe headache, visual disturbances, nausea, vomiting, and papilledema without sustained severe hypertension. Initial brain computed tomography was unremarkable, while subsequent magnetic resonance imaging demonstrated bilateral cortical and subcortical T2/fluid-attenuated inversion recovery hyperintensities with areas of diffusion restriction, consistent with complicated PRES. Cerebrospinal fluid analysis was unremarkable. Despite aggressive neurocritical care management and discontinuation of chemotherapy, her condition deteriorated rapidly and was complicated by cerebral edema and uncal herniation. Neurosurgical intervention was considered non-beneficial in the setting of advanced malignancy. This case highlights gemcitabine as a possible precipitating factor for PRES even in normotensive patients and underscores the diagnostic complexity when PRES coexists with advanced cancer and central nervous system involvement. Although PRES is often described as reversible, outcomes may be poor in such patients. Early recognition, prompt neuroimaging, withdrawal of the offending agent, and multidisciplinary management remain essential to optimize outcomes.