Pearls &amp; Oy-sters: Tacrolimus neurotoxicity presenting as an isolated brainstem lesion

Saadi, Altaf; Schmahmann, Jeremy D.

doi:10.1212/wnl.0000000000002467

Cited by 8 publications

(3 citation statements)

References 11 publications

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“…The drug has high lipophilicity, which facilitates its passage through blood-brain barrier to the brain, leading to cerebral vasodilatation and vasogenic edema [9]. Moreover, it can exert a direct neurotoxic effect, cytotoxic edema, direct endothelial damage, vasoconstriction, demyelination, or inhibition of the expression of drug-efflux pumps [10]. Radiologically, although the commonest presentation is described under the term of posterior reversible encephalopathy syndrome, several MRI studies have shown that imaging characteristics are variable and more heterogenous than commonly perceived [11].…”

Section: Discussionmentioning

confidence: 99%

Tacrolimus-Induced Leukoencephalopathy in a Renal Transplantation Patient

et al. 2022

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Tacrolimus is an immunosuppressant that is frequently used following renal transplantation. Several mild neurological side effects of tacrolimus have been reported in the literature; however, severe complications in the form of confusion, seizures, and coma are rare. Herein, we report a 16-year-old boy on tacrolimus following living-donor kidney transplant, who presented with subacute onset of hand tremors, headache, altered mental status, and progressed to akinetic mute state. He was diagnosed with tacrolimus-induced leukoencephalopathy based on findings of his magnetic resonance imaging and ruling out other possible causes. He showed clinical and radiological improvement after discontinuation of tacrolimus. Radiological features of tacrolimus-induced leukoencephalopathy are more heterogenous than commonly perceived and should be suspected in such patients. The potential neurotoxicity of tacrolimus should be recognized in patients with renal transplantation, and switching to a different immunosuppressant is warranted to prevent permanent neurological damage.

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Section: Discussionmentioning

confidence: 99%

Tacrolimus-Induced Leukoencephalopathy in a Renal Transplantation Patient

et al. 2022

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“…Isolated cases of brain stem involvement have also been reported. 13 , 14 In one study, 2/5 patients with tacrolimus toxicity had no reversal of white matter abnormalities upon discontinuation, even in the context of clinical improvement. 15 This appears similar to case 1 in which white matter lesions persisted after medication discontinuation.…”

Section: Discussionmentioning

confidence: 99%

“…Combined with a wide range in half-life (3.5–40.5 hours), normal plasma levels may not accurately reflect a patient's tacrolimus burden. 14 , 16 Studies have also found different genetic predispositions to drug pharmacokinetics that may increase susceptibility to CNS penetration, and presumably, optic nerve damage. 17 One case series suggested that transient breakdown in the blood-brain barrier due to graft-versus-host disease (GVHD) may also allow for increased CNS penetration.…”

Section: Discussionmentioning

confidence: 99%

Tacrolimus induced optic neuropathy in post-lung transplant patients: A series of 3 patients

Nanda¹,

Rasool²,

Bearelly³

2021

American Journal of Ophthalmology Case Reports

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Purpose Tacrolimus is a commonly used immunosuppressant medication after lung transplantation. In rare cases, tacrolimus causes a medication-induced optic neuropathy (TON) that can lead to significant vision loss. Observations In this series, we describe three cases of TON, 1–10 years after medication use. Two patients were young (22yr and 33yr) females with cystic fibrosis. The last case was a 65yr male with idiopathic pulmonary fibrosis. In 2/3 cases tacrolimus serum levels were normal. Visual acuity ranged from 20/20 to 20/300, and vision loss occurred acutely to sub-acutely, over a span of 2–3 months. Conclusions and importance As presented here, TON can be highly variable. MRI findings are often non-specific, from normal brain findings to extensive white matter changes. There remains an unclear association with graft-versus-host disease and reduced kidney function. Visual findings are often subtle, including color vision aberration and peripheral visual field deficits, both of which usually require an ophthalmologic evaluation. When diagnosed in a timely fashion, TON is at least partially reversible in up to half of all cases. While rare, the cases described here support post-lung transplant ophthalmologic evaluation in those taking high-risk medications.

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