Posterior Reversible Encephalopathy Syndrome After Orthotopic Heart Transplantation: A Case Report

Abstract

Patient: Female, 32Final Diagnosis: Posterior reversible encephalopathy syndromeSymptoms: SeizuresMedication: TacrolimusClinical Procedure: —Specialty: CardiologyObjective:Rare diseaseBackground:Calcineurin inhibitor-induced posterior reversible encephalopathy syndrome (PRES) is well described in liver and kidney transplant patients, but there is a paucity of data in heart transplant patients. PRES syndrome in the setting of heart transplantation can occur as early as 5 days following transplantation.Case Report:A 32-year-old woman who had recently undergone orthotopic heart transplantation developed headaches, visual disturbances, and generalized tonic clonic seizures 5 days after initiating anti-rejection therapy (tacrolimus, mycophenolate, and prednisone). No focal neurological deficits were noted on physical exam. Multifocal subcortical fluid attenuation inversion recovery (FLAIR) hyperintensity signals and areas of diffusion restriction with postcontrast enhancement, diagnostic of PRES, were found on MRI brain. Her symptoms resolved 2 days after tacrolimus was switched to cyclosporine. A follow-up MRI after 6 weeks demonstrated complete resolution of areas of flair hyperintensity signal. She was sent home on a short course of seizure prophylaxis, which was discontinued after the resolution of radiological findings. She had no further episodes of seizures for 6 months following discontinuation of her anti-epileptic regimen.Conclusions:Tacrolimus-induced PRES can occur as early as 5 days after orthotopic heart transplantation. Early recognition of symptoms and management can prevent permanent neurological sequelae.

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 ).…”

Encefalopatía posterior reversible en niño trasplantado de corazón

“…La toxicidad neurológica asociada al tacrolimus pueden tener manifestaciones leves como el temblor distal o graves como estatus epiléptico, alteraciones motoras o del lenguaje (14). La aparición de los efectos adversos no se relacionan con los niveles en sangre del medicamento, por lo cual se ha propuesto que es un efecto idiosincrático (7).…”

“…Dentro de las estrategias recomendadas para el tratamiento del síndrome de encefalopatía posterior reversible se enfatiza la importancia del diagnóstico temprano para prevenir las secuelas como el estatus epiléptico, la isquemia, la hemorragia y la herniación cerebral; además, retirar, disminuir o sustituir el inmunosupresor por otro del mismo grupo farmacológico o disminuir la dosis (1,14). En el caso descrito no se realizó ninguna de las opciones anteriores buscando evitar el rechazo agudo del injerto.…”

Posterior Reversible Encephalopathy Syndrome Associated with Tacrolimus in Cardiac Transplantation

“…Implant rejections were not reported. Consequently, this strategy may seem to be safe and effective for the management of tacrolimus-associated PRES [25][26][27]. Other approaches include switching to sirolimus, everolimus, mycophenolate mofetil, or hydrocortisone and lowering the dose of immunosuppressive agent.…”