• Masafumi Fukuda, Masakazu Nabeta, Takanori Muta, Tomonori Cho, Yutaka Shimamatsu, Yasutaka Shimotsuura, Kei Fukami, and Osamu Takasu.
• aAdvanced Emergency and Critical Care Center, Kurume University Hospital bDepartment of Emergency and Acute Intensive Care Medicine cDivision of Gastroenterology dDivision of Nephrology, Department of Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan.
• Medicine (Baltimore). 2020 Aug 14; 99 (33): e21743.

IntroductionFOLFOX therapy is the main chemotherapy regimen for colorectal cancer. Peripheral neuropathy, hematotoxicity, and digestive symptoms are known to be the most frequent adverse events. Hyperammonemia and lactic acidosis rarely occur simultaneously during treatment with FOLFOX therapy; the number of case reports is limited worldwide. We report a case of disturbance of consciousness, considered to be caused by hyperammonemia and lactic acidosis that occurred during treatment with mFOLFOX6 therapy that was administered as postoperative adjuvant treatment for rectal cancer.Patient ConcernsThis case was of a 71-year-old man who had been receiving oral treatment for chronic kidney disease and diabetes mellitus. Laparoscopic low anterior resection and artificial anal construction surgery were performed for stage III rectal cancer. As adjuvant postoperative therapy, mFOLFOX6 therapy was started but was followed by a disturbance of consciousness.DiagnosesResults of the blood tests revealed notable hyperammonemia (ammonia level, 1,163 μg/dl) and lactic acidosis (pH 7.207; lactate, 17.56 mmol/L); however, imaging diagnosis did not reveal intracranial lesions that could cause disturbance of consciousness.InterventionsFor hyperammonemia, branched-chain amino acid agents and Ringers solution supplementation were administered. For acidosis, 7% sodium hydrogen carbonate was administered as treatment.OutcomesThe disturbance of consciousness improved within 12 hours of initiating the treatment, and the patient was discharged with no sequelae on 7th day after hospitalization.ConclusionIn patients with chronic kidney disease, FOLFOX regimen may confer risks of hyperammonemia and lactic acidosis.

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