Calcineurin Inhibitors Associated Posterior Reversible Encephalopathy Syndrome in Solid Organ Transplantation

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a rare neurologic side effect of calcineurin inhibitors (CNIs) with poorly understood clinical features.We report cases of 2 patients with PRES developing after kidney transplantation and summarize PRES clinical features through a literature review.The 1st case was a 28-year-old man who received a kidney transplant from a deceased donor. Initial immunosuppressive therapy consisted of tacrolimus/mycophenolate mofetil/prednisolone. He developed headache and blurred vision with visual field loss15 days after transplantation and generalized seizures 4 days later. The 2nd case was a 34-year-old man who received a living kidney transplant. His initial immunosuppressive therapy comprised tacrolimus/mycophenolate mofetil/prednisolone. Two months after transplantation, he developed seizures. Both patients were diagnosed with PRES based on neurological symptoms and magnetic resonance imaging (MRI) findings; they recovered after switching from tacrolimus to either a cyclosporine or a lower tacrolimus dose. CNI-associated PRES is an acute neurological syndrome with seizures, encephalopathy, visual abnormalities, headache, focal neurological deficits, and nausea/vomiting. It is always accompanied by hypertension. A fluid-attenuated inversion recovery signal MRI scan typically shows reversible subcortical white matter changes in the posterior cerebral hemisphere that usually occur within the 1st month after transplantation. CNI-associated PRES has a generally favorable prognosis with early diagnosis and prompt treatment including alternating or discontinuing CNIs and blood pressure control.CNI-associated PRES should be considered in patients exhibiting acute neurological symptoms after transplantation. Early diagnosis and immediate treatment are critical for a favorable prognosis.

Neurotoxicity including posterior reversible encephalopathy syndrome after initiation of calcineurin inhibitors in transplanted methylmalonic acidemia patients: Two case reports and review of the literature

“…symptoms generally occur shortly after transplantation (days up to months). 19,25 This is confirmed in this study (all within 3 months after transplantation), while symptoms occurring more than a year after transplantation seem to be more likely metabolically induced, among other probably due to the entrapment of mma in the brain. 26 To gain more insight in the effect of transplantation on mma levels in CSF and to aid clinical interpretation of new neurological symptoms after transplantation, we recommend the measurement of mma CSF levels before/during and after transplantation in all to be transplanted MMA patients.…”

“…47,48 The incidence of CNI-induced PRES has been reported to range from 0.34% to 1% of the non-MMA patients after transplantation. 19,25,27 The incidence of CNI-induced neurotoxicity in transplanted MMA patients in this study seems comparable to the incidence with non-MMA transplanted patients, while the incidence of PRES seems much higher than in non-MMA transplanted patients.…”

Atypical Posterior Reversible Encephalopathy Syndrome Imaging on Liver Transplant Patients

“…Other important factor is the time between the procedure/start of the immunosuppression and the onset of neurologic symptoms, in our case clinical manifestations starts 7 months after the procedure, the literature describes an early onset related with use of CNI in patients after liver transplantation (LTx) usually within 2-3 months posttransplant [20]. despite this information a case of PRES occurring 13 months after LTx with CNI has been reported on 2005 [21] and in a case series of 19 subjects shows 1 patient who develops symptoms after 14 months of treatment with tacrolimus [22].…”

Posterior Reversible Encephalopathy Syndrome in Clinical Toxicology: A Systematic Review of Published Case Reports

“…In order to investigate the occurrence of PRES in poisoned patients, the authors systematically reviewed the scientific literature of case reports and case series concerning PRES associated with poisoning (i.e., alcohol, drugs, illicit drugs, natural toxins, chemical substances) in accidental context, intentional overdose, and substance abuse. The authors did not include cases of calcineurin inhibitor overexposure, which has already been covered (6). The purpose of this study is to raise awareness of the features of PRES in poisoned patients and encourage consistent and detailed reporting of PRES in a context of overdose and substance abuse.…”