Complex visual hallucinations and cyclosporine neurotoxicity

Systemic lupus erythematosus and ocular involvement: an overview

Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease of undefined etiology and with remarkably heterogeneous clinical features. Virtually any organ system can be affected, including the eye. SLE-related eye involvement can be diagnosed in approximately one-third of the patients and is usually indicative of disease activity. An early diagnosis and the adoption of suitable therapeutic measures are necessary to prevent sight-threatening consequences, especially in patients with juvenile SLE. Periocular lesions, such as eyelid involvement and orbital inflammation, are relatively rare and, in case of orbital masses, may require a biopsy control. Keratoconjunctivitis sicca or secondary Sjögren's syndrome is the most frequent ophthalmic manifestation of SLE. According to its variable severity, lubricating tear drops may be sufficient in mild cases, whereas cyclosporine-A ophthalmic solution, glucocorticoids (GCs), methotrexate, and/or other immunosuppressive drugs may be required in the more severe cases. Partial occlusion of the lacrimal punctum by thermal cautery is rarely applied. Although uncommon, episcleritis and scleritis can sometimes be detected as an initial finding of SLE and reveal themselves as moderate to intense ocular pain, redness, blurred vision, and lacrimation. Unilateral or more often bilateral retinopathy is responsible for visual loss of variable severity and is ascribed to vasculitis of the retinal capillaries and arterioles. In addition to the combined treatment suitable for all patients with active SLE, intravitreal bevacizumab should be considered in cases of severe vaso-occlusive retinopathy and laser photocoagulation in cases of neovascularization. Purtscher-like retinopathy is likely ascribable to the formation of microemboli that results in retinal vascular occlusion and microvascular infarcts. Choroidal disease is characterized by monolateral or bilateral blurred vision. Because of the choroidal effusion, retinal detachment and secondary angle-closure glaucoma may occur. Ischemic optic neuropathy is characterized by acute-onset and progressive binocular visual impairment as a consequence of occlusion of the small vessels of the optic nerves due to immune complex vasculitis. Intravenous GC boluses followed by oral GCs and/or, in case of recurrence, intravenous cyclophosphamide and/or rituximab are commonly employed. Neovascularization can be treated by intravitreal bevacizumab and progression of retinal ischemic areas by retinal laser photocoagulation. Ocular adverse events (AE) have been described following the long-term administration of one or more of the drugs presently used for the treatment of SLE patients. Posterior subcapsular cataracts and secondary open-angle glaucoma are common AE of the prolonged GC administration. The long-term administration of hydroxychloroquine (HCQ) sulfate is well known to be associated with AE, such as vortex keratopathy and in particular the often irreversible and sight-threatening maculopathy. Length of administration > 5 years, > 1000 g total HCQ consumption, > 6.5 mg/kg daily dosing, coexistence of renal disease, and preexisting maculopathy are all considered risk factors for HCQ-induced retinopathy. Ocular AE of additional immunosuppressive and biological agents are still poorly known, given the worldwide more limited experience with their long-term use. A thorough ophthalmological control is strongly recommended at closer intervals for all SLE patients, in step with the total length of exposure to the drugs and the cumulative dose administered.

Neurologic complications of transplantation

BACKGROUND

Organ transplantation is one of the most dynamic fields in medicine and has evolved into a life-saving option for thousands of patients with previously fatal conditions. The posttransplantation clinical course is frequently associated with neurologic complications that are usually related to pretransplant morbidity, the surgical procedure of transplantation, immunosuppression, and opportunistic infection.

REVIEW SUMMARY

Neurologic complications of organ transplantation may be divided into complications common to all types of allografts and complications that are specific for a particular type of organ transplantation. The most common complications include seizures, opportunistic central nervous system (CNS) infection, metabolic encephalopathy, stroke, intracranial hemorrhage, and drug-related adverse events. Opportunistic CNS infection may have a subtle presentation and should not be overlooked, as the consequences of delayed treatment may be grave. Neurotoxicity of immunosuppressive agents is also a frequent cause of neurologic complications and may occur in the setting of normal serum drug levels. The clinical course of transplant patients is frequently complex, requiring close cooperation between the transplant team and specialty consultants. Prolonged survival of transplant patients will shift the focus of neurologic complications from acute, perioperative to chronic complications of immunosuppression.

CONCLUSIONS

Neurologic complications of organ transplantation are commonly related to opportunistic infection or neurotoxicity of immunosuppressive agents, requiring careful titration of immunosuppression. Timely diagnosis of CNS infection or other causes of neurologic dysfunction may significantly improve recovery and outcome in these patients.

Central disorders of vision in humans

Over the past 20 years, researchers have discovered over 30 separate visual areas in the cortex of the macaque monkey that exhibit specific responses to visual and environmental stimuli. Many of these areas are homologous to regions of the human visual cortex, and numerous syndromes involving these areas are described in the neurologic and ophthalmic literature. The focus of this review is the anatomy and physiology of these higher cortical visual areas, with special emphasis on their relevance to syndromes in humans. The early visual system processes information primarily by way of two separate systems: parvocellular and magnocellular. Thus, even at this early stage, visual information is functionally segregated. We will trace this segregation to downstream areas involved in increasingly complex visual processing and discuss the results of lesions in these areas in humans. An understanding of these areas is important, as many of these patients will first seek the attention of the ophthalmologist, often with vague, poorly defined complaints that may be difficult to specifically define.

Cyclosporine-induced migraine with severe vomiting causing loss of renal graft

Successful use of cyclosporine in organ transplant can be associated with unwanted side-effects that can affect graft function. We report three kidney transplant recipients in whom severe migraine headache occurred as a side-effect of cyclosporine therapy. This endangered graft survival in all three and eventually led to loss of graft in two.

Hallucinations

Hallucinations, sensory perceptions without environmental stimuli, occur as simple experiences of auditory, gustatory, olfactory, tactile, or visual phenomena as well as mixed- or complex experiences of more than one simple phenomenon. The nature of the hallucination assists localization, differential diagnosis, and treatment planning. In particular, the presence of persistent visual hallucinations of persons with Parkinson's disease predicts dementia, rapid deterioration, permanent nursing home placement, and death. Hallucinations in persons with Alzheimer's disease are often associated with serious behavioral problems and predict a rapid cognitive decline. Theories of the etiology of hallucinations include (1) stimulation, e.g., neurochemical, electrical, seizure, and ephaptic, and (2) inhibition, e.g., destruction of normally inhibitory functions, resulting in disinhibition as in the Charles Bonnet and phantom limb syndromes. Functional neuroimaging procedures suggest anatomical associations for hallucinations. While hallucinations may be a symptom of medical, neurologic, and psychiatric disorders, they may also occur in a wide range of human experiences.

Side effects of immunosuppressant therapies used in neurology

This article provides an overview of the clinically relevant complications of the main immunosuppressants currently used in the treatment of neurologic disorders with suspected or established immune etiology. The most serious complications are discussed in detail, including pathophysiology and preventative measures. An intimate knowledge of these complications proves helpful in the day to day practice of the neurologist supervising immunotherapy.