Tocilizumab‐Associated Reversible Cerebral Vasoconstriction: A Case Report

Abstract

Objectives.-To report a case of reversible cerebral vasoconstriction syndrome (RCVS) possibly precipitated by tocilizumab. Background.-Immunosuppressant drugs are a rare cause of reversible cerebral vasoconstriction, a syndrome characterized by segmental vasospasm. However, although it is considered a reversible process that resolves within 3 months, the cerebral vasoconstriction over time may lead to severe complications such as strokes. Results.-We describe a 53-year-old woman who presented with a reversible vasoconstriction syndrome possibly associated with tocilizumab, an inhibitor of IL-6 receptor used in inflammatory diseases such as rheumatoid arthritis. The patient developed a cerebellar infarction as the major complication of the vasoconstriction syndrome. Conclusion.-Tocilizumab could be a trigger of RCVS. It is important to bear in mind the role of tocilizumab as a possible precipitating factor in order to remove it and reduce complications such as strokes. It is, to our knowledge, the first reversible vasoconstriction syndrome possibly precipitated by tocilizumab published to date. Key words: reversible cerebral vasoconstriction syndrome (RCVS), vasospasm, tocilizumab (IL-6 inhibitor), immunosuppressant drugs, adverse drug reaction (ADR) Abbreviations: ADC apparent diffusion coefficient, ADR adverse drug reaction, CT computed tomography, DWI diffusion-weighted imaging, EMA European Medicines Agency, FLAIR fast fluid-attenuated inversion recovery, PRES posterior reversible encephalopathy syndrome, RCVS reversible cerebral vasoconstriction syndrome, RMN cerebral magnetic resonance

Tacrolimus-induced Reversible Cerebral Vasoconstriction Syndrome after Heart Transplant: Case Report

“…In addition, like our case, some patients have refractory symptoms despite achieving a well-controlled blood pressure. This case emphasizes withdrawal of the causative drug as the most effective treatment for improving the symptoms, and for relieving cerebrovascular constrictions seen on subsequent imaging [4,5].…”

Reversible cerebral vasoconstriction syndrome: literature review

“…The largest studies suggest that 50–80% of patients will have a secondary cause for RCVS [ 1 , 10 , 19 , 35 , 41 , 44 ]. The main precipitating factors described are: postpartum state [ 7 , 10 , 13 , 14 , 16 , 25 , 31 , 35 , 39 , 45 – 47 ], drugs with vasoactive properties [ 10 , 12 – 14 , 36 , 39 , 47 , 48 ], such as cocaine, marijuana, and heroin [ 33 , 39 ], catecholamine-secreting tumors [ 35 , 49 – 51 ], autoimmune disorders, such as systemic vasculitis, systemic lupus erythematous, antiphospholipid syndrome [ 13 ], blood transfusions, ginseng [ 5 , 6 ], sexual intercourse, temperature differences (baths too hot or too cold), air travel [ 39 , 48 ], Corona Virus Disease 2019 (COVID-19) infection [ 36 , 52 – 54 ] and medications [ 6 , 29 , 39 , 48 ].…”

“…Nasal decongestants, immunosuppressants [ 9 , 29 , 48 ], antidepressants [ 39 ], oral contraceptive pills [ 6 ], indomethacin, and ergots, such as ergotamine tartrate, lisuride, methylergometrine and bromocriptine are some of the medications described in association with RCVS [ 6 ].…”

“…Reversible Cerebral Vasoconstriction Syndrome diagnosis is based on compatible clinical history, physical examination, and neuroimaging tests showing multifocal segmental vasoconstriction of cerebral arteries. Within 3 months, reversibility of this vasoconstriction occurs, evidenced in neuroimaging, however, some patients may persist with clinical deficits as well as complications, such as ischemic lesions and cerebral hemorrhage [ 9 , 16 , 17 , 48 , 62 , 64 ].…”

Pharmacovigilance of Biopharmaceuticals in Rheumatic Diseases, Adverse Events, Evolution, and Perspective: An Overview

“… Adverse biotherapeutic events in rheumatic diseases presented in case reports and case series [ 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 ]. …”