Tacrolimus-induced posterior reversible encephalopathy syndrome presenting as left upper limb monoplegia, convulsions, and sudden blindness: case report

Abstract

Background To report a case of sudden onset left upper limb monoplegia, convulsions, and bilateral blindness in a patient receiving tacrolimus for immunosuppression following living donor liver transplantation (LDLT) consistent with posterior reversible encephalopathy syndrome (PRES). Case presentation We report a case of a 64-year-old male patient on tacrolimus treatment following LDLT. On day 11, during his post-operative routine follow-up. The patient developed sudden onset of left upper limb monoplegia associated with attacks of convulsions and sudden bilateral blindness. MRI revealed multiple, bilateral cortical, and subcortical areas of high T2 and FLAIR signal intensity that did not show restricted diffusion. Findings were suggestive of posterior reversible encephalopathy syndrome (PRES). After the cessation of tacrolimus, vision was completely regained and all other neurologic symptoms were resolved, and follow-up MRI was normal. This case represents an uncommon presentation of tacrolimus toxicity. Conclusion Tacrolimus toxicity may present with PRES. Neurological deficits may be fully reversible with discontinuation of the drug; therefore, the early recognition and prompt management of this condition are of utmost importance.

Late presentation of posterior reversible encephalopathy syndrome following liver transplantation in the setting of tacrolimus and cannabis use

“…The occurrence of PRES in patients after transplantation secondary to tacrolimus is well-documented in the literature. This phenomenon has been observed in patients who have received liver ( 1 – 4 ), heart ( 5 , 6 ), kidney ( 7 – 9 ), and multivisceral transplants ( 10 ). In a retrospective chart review of 4,222 patients who underwent solid organ transplants, PRES developed in 21 (0.49%) patients ( 11 ).…”

An Unusual Presentation of Posterior Reversible Encephalopathy Syndrome Following Liver Transplantation

“…Some unusual clinical presentations like optic neuropathy with monoplegia and convulsions have also been reported. 16 …”

“… 20 , 21 It has also been observed that tacrolimus neurotoxicity is not dose related as seen in our patient. 16 , 22 There has been no literature showing association with timing of initiation of CNIs and the occurrence of PRES. The idiosyncratic neurotoxicity can be because of genetic polymorphisms in CYP3A5 that enhance susceptibility to tacrolimus-related neurotoxicity.…”

“…Some unusual clinical presentations like optic neuropathy with monoplegia and convulsions have also been reported. 16 The pathophysiology of PRES following LT has not been clearly understood. CNIs, because of their potent vasoconstrictor property, can result in excessive endothelin and reactive oxygen species production and vasogenic cerebral edema.…”