Tacrolimus-induced parkinsonism in a patient after liver transplantation – case report

Abstract

BackgroundHepatic encephalopathy may manifest by a wide spectrum of neuropsychiatric symptoms, including cognitive impairment, seizures or extrapyramidal symptoms. The liver transplant can lead to improvement of the signs of encephalopathy but subsequent immunosuppressive treatment might possess pronounced neurotoxicity.Case presentationWe present a case report of a patient with chronic liver disease who developed signs of Parkinsonism after an orthotopic liver transplant, with consecutive immunosuppressant treatment with tacrolimus. Despite the improvement of liver functions due to the cytostatic treatment, a progressive worsening of neuropsychiatric symptoms associated with the presence of tremor was observed. Metabolic as well as endocrine dysfunctions were excluded as the primary causes of this condition. A brain CT did not reveal structural pathology. Signs of severe, symmetric Parkinsonism - with resting tremor, bradykinesia, rigidity and severe postural instability were observed. A brain MRI was performed with the presence of T2- hyperintensities in basal ganglia bilaterally. Tacrolimus blood concentration was elevated; hence the dose was reduced and later switched to less toxic sirolimus. Subsequently, clinical signs markedly improved after treatment modification. Improvement of clinical symptomatology after tacrolimus discontinuation supports the drug-induced etiology of this neurological condition.ConclusionsCytostatic treatment after solid organ transplantation often leads to signs of encephalopathy. If necessary, the dose of cytostatics needs to be reduced, or a less toxic agent must be chosen for the therapy. This modification is usually efficient with no further need for neurological intervention.

Movement Disorders and Liver Disease

“…This is generally a symmetrical rest and action tremor of the upper limbs, though facial and lower limb muscles may be involved 122 . Other rarer manifestations include parkinsonism, opisthotonus and severe rigidity 123 . Severe toxicity may progress to stupor and coma 124 .…”

“… 122 Other rarer manifestations include parkinsonism, opisthotonus and severe rigidity. 123 Severe toxicity may progress to stupor and coma. 124 Neurological effects are not strictly dose‐dependent, and can occur with normal drug trough levels.…”

Reversible Parkinsonism caused by Influenza B‐associated encephalitis affecting bilateral basal ganglia: A case report

“…9,10 However, to our knowledge, Parkinsonism often occurs in the first several days of immuno-suppressive treatment. 9,10 And improvement of clinical symptoms will be noted after the discontinuation of cytostatic treatment. 9 Since our patient had a 6-year history of cytostatic treatment and his symptoms of Parkinsonism improved without withdrawal of the drugs, then this diagnosis was excluded.…”

Recent Topics on The Mechanisms of Immunosuppressive Therapy-Related Neurotoxicities

“…There are various neurological complications of CNIs, which can involve both the central nervous system (CNS) and the peripheral nervous system [37]. Mild neurological manifestations related to CNI toxicity are common and include tremors, insomnia, nightmares, sleep disturbances, headaches, vertigo, mood disturbances, and paresthesia (electric shock-like pain and severe itching) [38,39]. Serious adverse neurological effects have been relatively rarely observed and include seizures, speech disorders, cortical blindness, coma, encephalopathy, central pontine/extrapontine myelinolysis, and neuromuscular complications [14].…”