A Unique Case of Rituximab-Related Posterior Reversible Encephalopathy Syndrome in a Heart Transplant Recipient With Posttransplant Lymphoproliferative Disorder

Abstract

Rituximab is commonly used as a first line therapy to treat posttransplant lymphoproliferative disorders (PTLDs). It has also proved useful in the management of refractory antibody mediated graft rejection. We report an unusual case in which a heart transplant recipient being treated with rituximab for PTLD developed altered mental status, hallucinations and visual symptoms and magnetic resonance imaging (MRI) findings of symmetrical enhancement suggestive of posterior reversible leukoencephalopathy syndrome (PRES). Resolution of these clinical symptoms and radiological findings after discontinuation of therapy confirmed the diagnosis. This is the first case of PRES seen due to rituximab in a heart transplant recipient. Another unique feature of the case is the development of PRES after second cycle of rituximab as compared to prior reports in nonheart transplant patients in which the syndrome developed after first dose administration. The objective of this case report is to increase the awareness of this rare entity amongst immunocompromised transplant patients.

Neurologic Complications of Transplantation

“…These are likely underestimates as no prospective study has evaluated all potentially symptomatic patients with MRI; however, a prospective series in HSCT found PRES in 7%, with most occurring within the first thirty days [44]. Other factors may also precipitate PRES in transplant recipients, including hypertension, sepsis, renal failure, and other medications such as rituximab [45].…”

Rituximab‐associated posterior reversible encephalopathy syndrome

“…Notably, PRES occurred after the 2nd cycle of rituximab therapy in three patients. In one report, the re‐administration of rituximab was associated with recurrence of PRES . However, this was not demonstrated by others .…”

“…Rituximab usage in malignancy, organ transplant and in immune‐mediated diseases has been descried as a risk factor for the development of PRES . There is lack of randomized control trials evaluating use of rituximab in patients with SLE: it is sometimes used for relapsing and resistant cases.…”

Malignant Posterior Reversible Encephalopathy Syndrome—An Exacting Challenge for Neurocritical Care Physicians

“…Etiologies of PRES include immunotherapy 6 and agents like rituximab, 7 cisplatin, gemcitabine, bevacizumab, 8 tacrolimus, 9 and mycophenolate, 10 some autoimmune conditions like Henoch-Schonlein purpura, 5 thrombotic thrombocytopenic purpura, 5 systemic lupus erythematosus and systemic sclerosis, 11 and obstetrical conditions in which most commonly described are with cases of eclampsia 12 and chronic hypertension and renal failure, 13 HIV, 14 among others. Posterior reversible encephalopathy syndrome may develop suddenly as in our case due to stressors induced during a surgical procedure, fluctuating BP, or in a patient with an extensive and complicated history.…”