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Weiss N, Pflugrad H, Kandiah P. Altered Mental Status in the Solid-Organ Transplant Recipient. Semin Neurol 2024. [PMID: 39181120 DOI: 10.1055/s-0044-1789004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
Patients undergoing solid-organ transplantation (SOT) face a tumultuous journey. Prior to transplant, their medical course is characterized by organ dysfunction, diminished quality of life, and reliance on organ support, all of which are endured in hopes of reaching the haven of organ transplantation. Peritransplant altered mental status may indicate neurologic insults acquired during transplant and may have long-lasting consequences. Even years after transplant, these patients are at heightened risk for neurologic dysfunction from a myriad of metabolic, toxic, and infectious causes. This review provides a comprehensive examination of causes, diagnostic approaches, neuroimaging findings, and management strategies for altered mental status in SOT recipients. Given their complexity and the numerous etiologies for neurologic dysfunction, liver transplant patients are a chief focus in this review; however, we also review lesser-known contributors to neurological injury across various transplant types. From hepatic encephalopathy to cerebral edema, seizures, and infections, this review highlights the importance of recognizing and managing pre- and posttransplant neurological complications to optimize patient outcomes.
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Affiliation(s)
- Nicolas Weiss
- Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Neurological ICU, Paris, France
| | - Henning Pflugrad
- Department of Neurology, Agaplesion Ev. Klinikum Schaumburg, Obernkirchen, Germany
| | - Prem Kandiah
- Department of Neurology, Emory University Hospital, Atlanta, Georgia
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2
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Lim JH, Kim SH, Mo C, Kim HW, Lee SY. Clinical features and outcomes of posterior reversible encephalopathy syndrome after heart transplantation: a case series. CLINICAL TRANSPLANTATION AND RESEARCH 2024; 38:154-162. [PMID: 38910457 PMCID: PMC11228383 DOI: 10.4285/ctr.24.0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/21/2024] [Accepted: 06/04/2024] [Indexed: 06/25/2024]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disease that may be associated with hypertension, autoregulatory failure, and the use of calcineurin inhibitors following heart transplantation (HT). In this article, we present a case series of PRES, discussing its potential causes and management strategies. Among the 126 HT recipients at our hospital, four were diagnosed with PRES. Three of these patients developed PRES within 7 days after HT. Prior to the onset of PRES, all patients experienced sustained hypertension, and strict blood pressure (BP) control was maintained. Three of the four patients recovered without PRES recurrence, while one patient died of sepsis after an episode of altered consciousness. Hypertension was observed in all patients prior to the onset of PRES, and the majority experienced symptom improvement with BP control. While most cases of PRES were reversible with conservative treatment, including the administration of antiepileptics, one irreversible case resulted in in-hospital mortality. Thus, PRES can have serious outcomes and is not invariably benign.
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Affiliation(s)
- Ji Hoon Lim
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Seok Hyun Kim
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Cheolyong Mo
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Hyun-Woo Kim
- Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Soo Yong Lee
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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3
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Dehesa-Lopez E, Irizar-Santana SS, Valdez-Cruz MA, Sosa-Guerrero S, Lopez-Moreno F. Posterior Reversible Encephalopathy Syndrome With Hemorrhagic Transformation in the Postoperative Period of a Kidney Transplant. Cureus 2024; 16:e55584. [PMID: 38576656 PMCID: PMC10993100 DOI: 10.7759/cureus.55584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/06/2024] Open
Abstract
Patients with end-stage renal disease (ESRD) who undergo kidney transplantation are at an increased risk of developing surgical and/or medical complications. Posterior reversible encephalopathy syndrome (PRES) is a rare complication that occurs in 0.34% of kidney transplant patients. It is characterized by a combination of neurological manifestations, risk factors, and characteristic radiological findings in neuroimaging studies. The development of PRES has been associated with various medical conditions and factors, including hypertension, the use of cytotoxic and immunosuppressive drugs, acute or chronic kidney disease, pre-eclampsia/eclampsia, autoimmune diseases, and solid organ and bone marrow transplantation. This report presents the case of a 19-year-old woman diagnosed with ESRD on hemodialysis due to lupus nephritis who experienced an episode of PRES with intraparenchymal hemorrhage during the postoperative period of kidney transplantation. The case emphasizes the importance of closely monitoring these patients during this period to enable early diagnosis and timely treatment of complications, ensuring a favorable prognosis.
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4
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Affiliation(s)
- Romergryko G Geocadin
- From the Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
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5
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Fiorentino M, Bagagli F, Deleonardis A, Stasi A, Franzin R, Conserva F, Infante B, Stallone G, Pontrelli P, Gesualdo L. Acute Kidney Injury in Kidney Transplant Patients in Intensive Care Unit: From Pathogenesis to Clinical Management. Biomedicines 2023; 11:1474. [PMID: 37239144 PMCID: PMC10216683 DOI: 10.3390/biomedicines11051474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/05/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Kidney transplantation is the first-choice treatment for end-stage renal disease (ESRD). Kidney transplant recipients (KTRs) are at higher risk of experiencing a life-threatening event requiring intensive care unit (ICU) admission, mainly in the late post-transplant period (more than 6 months after transplantation). Urosepsis and bloodstream infections account for almost half of ICU admissions in this population; in addition, potential side effects related to immunosuppressive treatment should be accounted for cytotoxic and ischemic changes induced by calcineurin inhibitor (CNI), sirolimus/CNI-induced thrombotic microangiopathy and posterior reversible encephalopathy syndrome. Throughout the ICU stay, Acute Kidney Injury (AKI) incidence is common and ranges from 10% to 80%, and up to 40% will require renal replacement therapy. In-hospital mortality can reach 30% and correlates with acute illness severity and admission diagnosis. Graft survival is subordinated to baseline estimated glomerular filtration rate (eGFR), clinical presentation, disease severity and potential drug nephrotoxicity. The present review aims to define the impact of AKI events on short- and long-term outcomes in KTRs, focusing on the epidemiologic data regarding AKI incidence in this subpopulation; the pathophysiological mechanisms underlying AKI development and potential AKI biomarkers in kidney transplantation, graft and patients' outcomes; the current diagnostic work up and management of AKI; and the modulation of immunosuppression in ICU-admitted KTRs.
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Affiliation(s)
- Marco Fiorentino
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Francesca Bagagli
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Annamaria Deleonardis
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Alessandra Stasi
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Rossana Franzin
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Francesca Conserva
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Barbara Infante
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, 71122 Foggia, Italy
| | - Giovanni Stallone
- Nephrology, Dialysis and Transplantation Unit, Department of Medical and Surgical Science, University of Foggia, 71122 Foggia, Italy
| | - Paola Pontrelli
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari “Aldo Moro”, 70121 Bari, Italy; (M.F.)
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6
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Posterior Reversible Encephalopathy Syndrome in a Patient With Primary Hyperaldosteronism (Conn Syndrome). J Neuroophthalmol 2023; 43:e9-e11. [PMID: 34629405 DOI: 10.1097/wno.0000000000001351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Balcerac A, Bihan K, Psimaras D, Lebrun-Vignes B, Salem JE, Weiss N. Drugs associated with posterior reversible encephalopathy syndrome, a worldwide signal detection study. J Neurol 2023; 270:975-985. [PMID: 36329183 DOI: 10.1007/s00415-022-11450-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) can occur in a variety of clinical conditions, such as severe hypertension, pregnancy, inflammatory diseases, hematopoietic stem cells or solid organ transplantation. Apart increased blood pressure levels and altered renal function, several drugs have been reported as potential triggering factor. These descriptions are nevertheless limited to case reports or small case series. Systematic analysis of drugs associated with PRES using global pharmacovigilance database is lacking and can be useful. METHODS We performed a disproportionality analysis using VigiBase, the World Health Organization pharmacovigilance database, using the information component (IC). The IC compares observed and expected values to find associations between drugs and PRES using disproportionate Bayesian reporting. An IC0.25 (lower end of the IC 95% credibility interval) > 0 is considered statistically significant. RESULTS Here we present an analysis of 3278 cases of PRES reported in VigiBase. These results identified 73 molecules statistically associated with PRES using full database as background with an IC0.25 > 0. Only 34% (N = 25/73) of them had this information written in the summary of product characteristics. The main drug classes involved were antineoplastic and immunomodulating agents and the drugs with the greatest number of cases were tacrolimus, cyclosporin, bevacizumab, methotrexate, and vincristine. An overall mortality of 8.1% (N = 267/3278) was identified in cases of drug-associated PRES. CONCLUSION These results will help clinicians identify potential suspected drugs associated with PRES and decide which drug to discontinue and eventually lead to a re-evaluation of drug labels for some molecules.
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Affiliation(s)
- Alexander Balcerac
- département de neurologie, unité de Médecine Intensive Réanimation à orientation neurologique, Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Paris, France. .,Groupe de Recherche Clinique en REanimation et Soins intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE) Sorbonne Université, 47-83, boulevard de l'hôpital, 75013, Paris, France.
| | - Kevin Bihan
- Department of Pharmacology, Regional Pharmacovigilance Center, Sorbonne Université, AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901, Sorbonne Universités, Paris, France
| | - Dimitri Psimaras
- service de neuro-oncologie, DMU Neurosciences, Groupe OncoNeuro Tox, Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Paris, France
| | - Bénédicte Lebrun-Vignes
- Department of Pharmacology, Regional Pharmacovigilance Center, Sorbonne Université, AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901, Sorbonne Universités, Paris, France
| | - Joe-Elie Salem
- Department of Pharmacology, Regional Pharmacovigilance Center, Sorbonne Université, AP-HP.Sorbonne Université, Pitié-Salpêtrière Hospital, INSERM, CIC-1901, Sorbonne Universités, Paris, France
| | - Nicolas Weiss
- département de neurologie, unité de Médecine Intensive Réanimation à orientation neurologique, Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Paris, France.,Groupe de Recherche Clinique en REanimation et Soins intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE) Sorbonne Université, 47-83, boulevard de l'hôpital, 75013, Paris, France
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8
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Yavuz G, Heck S, Sienel W, Irlbeck M, Kneidinger N, Michel S, Forbrig R, Walter J, Zimmermann J, Kovács J, Glück OM, Pan M, Schneider C, Fertmann JM, Hatz RA, Kauke T. Posterior reversible encephalopathy syndrome after lung transplantation: Risk factors and management. Clin Transplant 2023; 37:e14850. [PMID: 36398875 DOI: 10.1111/ctr.14850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Posterior reversible encephalopathy syndrome is a rare neurologic complication that can occur under immunosuppressive therapy with CNI after organ transplantation. METHODS We retrospectively reviewed medical records of 545 patients who underwent lung transplantation between 2012 and 2019. Within this group, we identified 30 patients with neurological symptoms typical of PRES and compared the characteristics of patients who were diagnosed with PRES (n = 11) to those who were not (n = 19). RESULTS The incidence of PRES after lung transplantation was 2%. Notably, 73% of the patients with PRES were female and the mean age was 39.2. Seizure (82% vs. 21%, p = .002) was the most common neurological presentation. The risk of developing PRES was significantly associated with age (OR = .92, p < .0001) and having cystic fibrosis (CF) (OP = 10.1, p < .0001). Creatinine level (1.9 vs. 1.1 mg/dl, p = .047) and tacrolimus trough level (19.4 vs. 16.5 ng/ml, p = .048) within 1 week prior to neurological symptoms were significantly higher in patients with PRES. CONCLUSION Renal insufficiency and high tacrolimus levels are associated with PRES. A change of immunosuppressive drug should be done after confirmed PRES diagnosis or immediately in case of severe neurological dysfunction to improve neurological outcomes and minimize the risk of early allograft rejection.
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Affiliation(s)
- Gökce Yavuz
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Suzette Heck
- Department of Neurology, University Hospital of Munich, LMU, Munich, Germany
| | - Wulf Sienel
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, University Hospital of Munich, LMU, Munich, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, University Hospital of Munich, LMU, Munich, Germany
| | - Sebastian Michel
- Department of Cardiac Surgery, University Hospital of Munich, LMU, Munich, Germany.,Comprehensive Pneumology Center Munich, German Center for Lung Research (DZL), Munich, Germany
| | - Robert Forbrig
- Department of Neuroradiology, University Hospital of Munich, LMU, Munich, Germany
| | - Julia Walter
- Department of Internal Medicine V, University Hospital of Munich, LMU, Munich, Germany
| | - Julia Zimmermann
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Julia Kovács
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Olaf M Glück
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Ming Pan
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Christian Schneider
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Jan M Fertmann
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Rudolf A Hatz
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany
| | - Teresa Kauke
- Department of Thoracic Surgery, University Hospital of Munich, LMU, Munich, Germany.,Transplant Center, University Hospital of Munich, LMU, Munich, Germany
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9
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Acute obstructive hydrocephalus in posterior reversible encephalopathy syndrome. S Afr Med J 2022; 113:9-12. [PMID: 36537543 DOI: 10.7196/samj.2023.v113i1.16744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an uncommon, subacute neurological disorder that presents radiologically with a pattern of bilateral parieto-occipital areas of vasogenic oedema. Conditions commonly associated with PRES include autoimmune disorders, cytotoxic drugs, metabolic abnormalities and, most frequently, hypertensive emergencies. Clinically, headache, visual disturbances, seizures and an altered level of consciousness are often reported. The outcome is favourable if the underlying cause is addressed. Posterior fossa involvement resulting in obstructive hydrocephalus is a rare presentation and may be misdiagnosed as a mass lesion or infection, leading to delayed or unnecessary treatment. We describe the clinical presentation, findings on neuroimaging and conservative management of a man with PRES resulting in severe cerebellar oedema and acute obstructive hydrocephalus. This case illustrates that awareness of atypical neuroimaging in PRES is important for the management of these patients and to avoid morbidity and mortality.
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10
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Bugallo-Carrera C, Facal D, Domínguez-Lenogue C, Álvarez-Vidal V, Gandoy-Crego M, Caamaño-Ponte J. Neuropsychiatric Symptoms after Liver Transplantation in a 65-Year-Old Male Patient. Brain Sci 2022; 12:1721. [PMID: 36552180 PMCID: PMC9776108 DOI: 10.3390/brainsci12121721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 12/07/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
The development of immunosuppressants has been key for the advancement of solid organ transplant surgery. Specifically, cyclosporine, tacrolimus, or everolimus have significantly increased the survival rate of patients by reducing the risk of a rejection of the transplanted organ and limiting graft-versus-host disease. We report the case of a 65-year-old man who, after undergoing a liver transplantation and receiving an immunosuppressive treatment with cyclosporine and everolimus, presented severe obsessive, psychotic, and behavioral symptoms over the past three years, and describe the pharmacological and non-pharmacological interventions implemented against these symptoms. In this case, the immunosuppressants used have been cyclosporine and, preferably, everolimus. On the other hand, potential adverse reactions to the treatment have been observed, including neuropsychiatric symptoms such as tremor, anxiety, dysthymia, psychosis, and behavioral disorders, which make it necessary to use corrective psychoactive drugs such as benzodiazepines, antidepressants, and antipsychotics, combined with non-pharmacological interventions. A transversal approach, from the medical and psychosocial disciplines, facilitates success in managing neuropsychiatric symptoms after soft organ transplants.
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Affiliation(s)
- Cesar Bugallo-Carrera
- Asociación de Familiares de Enfermos de Alzheimer de Fisterra e Soneira—Afafes. Cee, 15270 A Coruña, Spain
- Department of Developmental Psychology, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
| | - David Facal
- Department of Developmental Psychology, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
| | - Cristina Domínguez-Lenogue
- Asociación de Familiares de Enfermos de Alzheimer de Fisterra e Soneira—Afafes. Cee, 15270 A Coruña, Spain
| | - Vanessa Álvarez-Vidal
- Hospital de Día de Procesos, Servicio de Geriatría, Hospital Universitario Lucus Augusti, 27003 Lugo, Spain
| | - Manuel Gandoy-Crego
- Department of Psychiatry, Radiology, Public Health, Nursing and Medicine, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
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11
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Tarhan G, Karabulut EGT, Karacı R, Sönmez Güngör E, Kaya GK, Ülker M, Domaç SF. Multiorgan dysfunction precipitated by disulfiram use and posterior reversible encephalopathy syndrome with atypical presentation: a case report. JOURNAL OF SUBSTANCE USE 2022. [DOI: 10.1080/14659891.2022.2153758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Güllü Tarhan
- Department of Neurology, Erenkoy Mental and Nervous Diseases Training and Research Hospital, Istanbul, Turkey
| | - Elif Gözde Türedi Karabulut
- Department of Neurology, Erenkoy Mental and Nervous Diseases Training and Research Hospital, Istanbul, Turkey
| | - Rahşan Karacı
- Department of Neurology, Erenkoy Mental and Nervous Diseases Training and Research Hospital, Istanbul, Turkey
| | - Ekin Sönmez Güngör
- Department of Psychiatry, Erenkoy Mental and Nervous Diseases Training and Research Hospital, Istanbul, Turkey
| | - Gökçe Keskin Kaya
- Department of Neurology, Erenkoy Mental and Nervous Diseases Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Ülker
- Department of Neurology, Erenkoy Mental and Nervous Diseases Training and Research Hospital, Istanbul, Turkey
| | - Saime Füsun Domaç
- Department of Neurology, Erenkoy Mental and Nervous Diseases Training and Research Hospital, Istanbul, Turkey
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12
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Model-informed Estimation of Acutely Decreased Tacrolimus Clearance and Subsequent Dose Individualization in a Pediatric Renal Transplant Patient with Posterior Reversible Encephalopathy Syndrome. Ther Drug Monit 2022; 45:376-382. [PMID: 36728342 DOI: 10.1097/ftd.0000000000001045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/22/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Considerable inter-patient and inter-occasion variability has been reported in tacrolimus pharmacokinetics (PK) in the pediatric renal transplant population. The present study investigated tacrolimus PK in a 2-year-old post-renal transplant patient and a known CYP3A5 expresser who developed posterior reversible encephalopathy syndrome (PRES) and had significantly elevated tacrolimus blood concentrations during tacrolimus treatment. A model-informed PK assessment was performed to assist with precision dosing. Tacrolimus clearance was evaluated both before and after the development of PRES on post-transplant day (PTD) 26. METHODS A retrospective chart review was conducted to gather dosing data and tacrolimus concentrations, as part of a clinical pharmacology consultation service. Individual PK parameters were estimated by Bayesian estimation using a published pediatric PK model. Oral clearance (CL/F) was estimated for three distinct time periods-before CNS symptoms (PTD 25), during the PRES event (PTD 27-30), and after oral tacrolimus was re-started (PTD 93). RESULTS Bayesian estimation showed an estimated CL/F of 15.0 L/h in the days preceding the PRES event, compared to a population mean of 16.3 L/h (95% confidence interval 14.9-17.7 L/h) for CYP3A5 expressers of the same age and weight. Samples collected on PTD 27-30 yielded an estimated CL/F of 3.6 L/h, a reduction of 76%, coinciding with clinical confirmation of PRES and therapy discontinuation. On PTD 93, an additional assessment showed a stable CL/F value of 14.5 L/h one month after re-initiating tacrolimus and was used to recommend a continued maintenance dose. CONCLUSION This is the first report to demonstrate acutely decreased tacrolimus clearance in PRES, likely caused by the downregulation of metabolizing enzymes in response to inflammatory cytokines. The results suggest the ability of model-informed Bayesian estimation to characterize an acute decline in oral tacrolimus clearance after the development of PRES, and the role that PK estimation may play in supporting dose selection and individualization.
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Kemna MS, Shaw DW, Kronmal RA, Ameduri RK, Azeka E, Bradford TT, Kindel SJ, Lin KY, Möller T, Reardon LC, Schumacher KR, Shih R, Stendahl GL, West SC, Wisotzkey B, Zangwill S, Menteer J. Posterior reversible encephalopathy syndrome (PRES) after pediatric heart transplantation: A multi-institutional cohort. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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14
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Nagano Y, Iwai T, Tomita M, Kimura H, Kosoku A, Kabei K, Nishide S, Machida Y, Uchida J. A Case of Posterior Reversible Encephalopathy Syndrome Developing 10 Years After Kidney Transplant. EXP CLIN TRANSPLANT 2022; 20:630-632. [DOI: 10.6002/ect.2022.0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Kharbat AF, Calles P, Ogle A, Vasylyeva TL, Pinkney K. A Case of Pediatric Posterior Reversible Encephalopathy Syndrome (PRES) Secondary to Post-streptococcal Glomerulonephritis: A Literature Review and Assessment of Treatment Modalities. Cureus 2022; 14:e25113. [PMID: 35733462 PMCID: PMC9205275 DOI: 10.7759/cureus.25113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/18/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a disorder that most commonly affects adults, and is characterized by neurologic symptoms such as encephalopathy, seizures, headaches, and visual disturbances. It usually occurs in the context of other systemic disturbances that result in hypertensive crises, such as renal failure, cytotoxic drugs, and autoimmune conditions. In children, it rarely manifests following chemotherapy induction or hematopoietic stem cell transplantation. No cases have been reported in the English literature connecting renal dysfunction and hypertensive emergency secondary to post-streptococcal glomerulonephritis (PSGN) with PRES. We present a case of an eight-year-old boy, who developed a constellation of symptoms suggestive of PSGN and later developed PRES. PRES is often confirmed upon suspicion through brain MRI showing subcortical edema of various brain regions including occipital, temporal, or parietal cortices. Our patient demonstrated subcortical edema of the bilateral occipital lobes and right cerebellar hemisphere, with positive antistreptolysin O (ASO) titers demonstrating PSGN as the likely etiology for his hypertensive emergency. Management included antihypertensive and anticonvulsant treatment, which allowed the resolution of the offending hypertensive emergency that resulted in PRES. Our case adds to the growing body of literature on PRES and describes a new etiology of pediatric PRES secondary to PSGN.
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Foulser PFG, Senthivel N, Downey K, Hart PE, McGrath SE. Posterior reversible encephalopathy syndrome associated with use of Atezolizumab for the treatment of relapsed triple negative breast cancer. Cancer Treat Res Commun 2022; 31:100548. [PMID: 35305364 DOI: 10.1016/j.ctarc.2022.100548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 03/09/2022] [Accepted: 03/10/2022] [Indexed: 06/14/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a complex neurological disorder with multiple clinical manifestations including headaches, seizures, and altered mental status. It is associated with many conditions including malignancy and medications including chemotherapy and immunotherapy. We report the case of a 56-year old female with a history of advanced triple negative breast cancer treated with atezolizumab (a PD-L1 inhibitor), paclitaxel and ipatasertib (investigational AKT inhibitor), who developed hypertension, confusion, and imaging findings consistent with PRES.
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Affiliation(s)
- Peter F G Foulser
- Royal Marsden Hospital, Sutton, Downs Road, Sutton, SM2 5PT, United Kingdom.
| | | | - Kate Downey
- Royal Marsden Hospital, Sutton, Downs Road, Sutton, SM2 5PT, United Kingdom
| | - Paul E Hart
- Royal Marsden Hospital, Sutton, Downs Road, Sutton, SM2 5PT, United Kingdom
| | - Sophie E McGrath
- Royal Marsden Hospital, Sutton, Downs Road, Sutton, SM2 5PT, United Kingdom
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17
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Zhou F, Costa AF, McLeod M. Late presentation of posterior reversible encephalopathy syndrome following liver transplantation in the setting of tacrolimus and cannabis use. CANADIAN LIVER JOURNAL 2022; 5:91-95. [PMID: 35990782 PMCID: PMC9231424 DOI: 10.3138/canlivj-2021-0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 07/24/2021] [Indexed: 07/29/2023]
Abstract
A 45-year-old female presented to hospital with confusion and visual disturbances. She had undergone a liver transplant 3 years prior for cirrhosis secondary to primary biliary cholangitis. Computed tomography and magnetic resonance imaging of the brain showed features consistent with posterior reversible encephalopathy syndrome. Her medications included tacrolimus, sirolimus, and prednisone. She reported smoking 4 grams of cannabis per day. Following cessation of tacrolimus, the patient's encephalopathy and visual disturbances resolved. To our knowledge, this case represents the longest time elapsed from liver transplantation to the development of tacrolimus-associated posterior reversible encephalopathy syndrome in the literature. This case highlights the potential danger of cannabis use in transplant recipients who are on immunosuppressants such as tacrolimus. Clinicians should have a high index of suspicion for posterior reversible encephalopathy syndrome in post-transplant patients presenting with altered mental status, even years after liver transplantation, and be familiar with potential interactions between cannabis and immunosuppressants.
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Affiliation(s)
- Felix Zhou
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andreu F Costa
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Magnus McLeod
- Division of General Internal Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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18
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Triplett JD, Kutlubaev MA, Kermode AG, Hardy T. Posterior reversible encephalopathy syndrome (PRES): diagnosis and management. Pract Neurol 2022; 22:183-189. [PMID: 35046115 DOI: 10.1136/practneurol-2021-003194] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 01/31/2023]
Abstract
Posterior reversible encephalopathy syndrome (PRES) may present with diverse clinical symptoms including visual disturbance, headache, seizures and impaired consciousness. MRI shows oedema, usually involving the posterior subcortical regions. Triggering factors include hypertension, pre-eclampsia/eclampsia, renal failure, cytotoxic agents and autoimmune conditions. The mechanism underlying PRES is not certain, but endothelial dysfunction is implicated. Treatment is supportive and involves correcting the underlying cause and managing associated complications, such as seizures. Although most patients recover, PRES is not always reversible and may be associated with considerable morbidity and even mortality.
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Affiliation(s)
- James D Triplett
- Neurology, Concord Hospital, Concord, New South Wales, Australia
| | | | - Allan G Kermode
- Perron Institute, University of Western Australia, Perth, Western Australia, Australia.,CMMIT, Murdoch University, Murdoch, Western Australia, Australia
| | - Todd Hardy
- Neurology, Concord Hospital, Concord, New South Wales, Australia.,Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
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19
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An Unusual Presentation of Posterior Reversible Encephalopathy Syndrome Following Liver Transplantation. Transplant Direct 2022; 8:e1269. [PMID: 35018303 PMCID: PMC8735783 DOI: 10.1097/txd.0000000000001269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/18/2021] [Accepted: 10/30/2021] [Indexed: 12/07/2022] Open
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20
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Balu R, Fischer M. Posterior Reversible Encephalopathy Syndrome. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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21
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Ueno T, Toyama C, Deguchi K, Masahata K, Nomura M, Watanabe M, Kamiyama M, Tazuke Y, Bessho K, Okuyama H. Long-Term Outcome After Tacrolimus-Related Neurotoxicity in Pediatric Living Donor Liver Transplantation. Transplant Proc 2022; 54:468-471. [PMID: 35074159 DOI: 10.1016/j.transproceed.2021.12.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/29/2021] [Indexed: 01/14/2023]
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22
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Mergen S, Long B, Matlock A. Posterior Reversible Encephalopathy Syndrome: A Narrative Review for Emergency Clinicians. J Emerg Med 2021; 61:666-673. [PMID: 34696929 DOI: 10.1016/j.jemermed.2021.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiologic disorder characterized by seizures, headache, altered mental status, and visual disturbances, and is often associated with acute hypertension. OBJECTIVE This narrative review provides a focused description of the presentation, diagnostic evaluation, and management of PRES. DISCUSSION PRES is associated with a variety of factors, including acute rise in blood pressure, renal disease, preeclampsia/eclampsia, and immunosuppressive therapy. The pathophysiology is theorized to involve dysfunction of cerebral autoregulation leading to vascular leak or endothelial dysfunction resulting in vasogenic edema. In the emergency department (ED), clinical findings suggestive of PRES should prompt diagnostic testing focused on confirming the diagnosis and excluding other conditions that may present similarly. Laboratory studies are primarily useful for excluding alternative diagnoses. Computed tomography (CT) and, in particular, magnetic resonance imaging (MRI) are the recommended neuroimaging modalities for diagnosis. CT and MRI may demonstrate cerebral vasogenic edema, most often in the distribution of the posterior circulation. Treatment involves management of seizures, control of blood pressure if elevated, and treatment of any underlying trigger. CONCLUSION PRES is a neurological disorder that is typically reversible if recognized on presentation and promptly and appropriately managed. This narrative review characterizes this condition for emergency clinicians.
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Affiliation(s)
- Stephanie Mergen
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Aaron Matlock
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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23
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Yamamoto S, Nagashima T, Akiyama Y, Nagatani K, Iwamoto M, Minota S. Fatal Thrombotic Microangiopathy and Posterior Reversible Encephalopathy Syndrome in a Patient with Anti-melanoma Differentiation-associated Gene 5 Antibody-positive Dermatomyositis. Intern Med 2021; 60:3329-3333. [PMID: 33896869 PMCID: PMC8580758 DOI: 10.2169/internalmedicine.7309-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 56-year-old woman presented with dermatomyositis positive for anti-melanoma differentiation-associated gene 5 antibody. No interstitial lung disease was detected. Despite treatment with methylprednisolone pulse therapy and cyclosporine, dysphagia developed. Furthermore, the presence of thrombocytopenia, elevated lactate dehydrogenase levels, and an undetectable haptoglobin level suggested the possibility of thrombotic microangiopathy (TMA). Disturbed consciousness developed shortly after TMA onset, and brain magnetic resonance imaging revealed hyperintensity lesions in the bilateral basal ganglia, thalami, and brainstem. The patient was diagnosed with atypical posterior leukoencephalopathy syndrome before dying of heart failure later that day. In conclusion, early TMA recognition and prompt intensive treatment are critical in such cases.
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Affiliation(s)
- Shotaro Yamamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Takao Nagashima
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Yoichiro Akiyama
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Katsuya Nagatani
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Masahiro Iwamoto
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
| | - Seiji Minota
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Jichi Medical University, Japan
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24
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Atça AÖ, Erok B, Aydoğdu S. Neuroimaging findings of posterior reversible encephalopathy syndrome (PRES) following haematopoietic stem cell transplantation in paediatric recipients. BMC Pediatr 2021; 21:445. [PMID: 34629063 PMCID: PMC8504064 DOI: 10.1186/s12887-021-02890-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 09/09/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Haematopoietic stem cell transplantation (HSCT) is used worldwide in various malignant and nonmalignant childhood diseases, including haematologic, genetic, autoimmune and metabolic disorders, and is the only curative treatment for many of these illnesses. The survival rates of many childhood diseases have been increased due to HSCT treatment. However, associated complications are still important for management. Central nervous system (CNS) complications in paediatric HSCT recipients can be associated with high morbidity and significantly contribute to mortality. Posterior reversible encephalopathy syndrome (PRES) is one of the most common CNS complications in patients with neurological symptoms following HSCT. Magnetic resonance imaging (MRI) is the modality of choice and shows typical bilateral vasogenic oedema at the posterior parts of the cerebral hemispheres; however, various atypical imaging manifestations can also occur. In this study, we retrospectively examined CNS complications in our paediatric HSCT recipients with a focus on the typical and atypical neuroimaging manifestations of PRES following HSCT. METHODS We retrospectively reviewed the medical records of 300 consecutive paediatric HSCT recipients from January 2014 to November 2018. A total of 130 paediatric HSCT recipients who experienced neurological signs and symptoms and were evaluated with neuroimaging studies following HSCT were enrolled in the study. The timing of CNS complications was defined according to immune status, including the pre-engraftment period (< 30 days after HSCT), the early postengraftment period (30-100 days after HSCT), and the late postengraftment period (> 100 days after HSCT), which were defined as phases 1, 2 and 3, respectively. RESULTS Overall, 130 paediatric HSCT recipients experienced neurological signs and symptoms and therefore underwent neuroimaging examinations. Among these 130 patients, CNS complications were present in 23 patients (17.6%, 23/130), including 13 (56.5%) females and 10 (43.5%) males with a median age of 8.0 years (range, 8 months to 18.0 years). Among these 23 patients, 14 cases of PRES (60.9%), 5 (21.7%) cases of leukoencephalopathy, 3 cases of acute subdural haemorrhage (ASDH) (13%) and 1 (4.3%) case of fungal CNS infection were identified by neuroimaging. On MRI, typical parietooccipital vasogenic oedema was present in 78.5% of the PRES cases (11/14). The following atypical neuroimaging manifestations were observed: isolated involvement of the bilateral frontal lobes in 1 case, isolated cerebellar vermis involvement in 1 case, and isolated basal ganglia involvement in 1 case. Restricted diffusion associated with cytotoxic damage was demonstrated in 2 of 14 cases, one of which also showed subacute cytotoxic injury with ADC pseudonormalization. CONCLUSION Paediatric HSCT recipients presenting with CNS signs and symptoms should be evaluated by neuroimaging studies for timely diagnosis and early management. PRES is the most common CNS complication and may present with atypical MRI manifestations, which should not dissuade a PRES diagnosis in appropriate clinical settings.
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Affiliation(s)
- Ali Önder Atça
- Department of Radiology, Altınbas University School of Medicine Bahcelievler Medical Park Hospital, İstanbul, Turkey
| | - Berrin Erok
- Department of Radiology, University of Health Sciences, Prof Dr Cemil Tascıoglu City Hospital, Istanbul, Turkey.
| | - Selime Aydoğdu
- Department of Hematology, Altınbas University School of Medicine Bahcelievler Medical Park Hospital, İstanbul, Turkey
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25
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Singhal AB. Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome as Syndromes of Cerebrovascular Dysregulation. Continuum (Minneap Minn) 2021; 27:1301-1320. [PMID: 34618761 DOI: 10.1212/con.0000000000001037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article describes the causes, clinical and imaging features, management, and prognosis of posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS), in which the underlying pathophysiology is related to reversible dysregulation of the cerebral vasculature. RECENT FINDINGS PRES and RCVS are descriptive terms, each bringing together conditions with similar clinical-imaging manifestations. Headache, visual symptoms, seizures, and confusion occur in both syndromes. RCVS is usually heralded by recurrent thunderclap headaches, whereas encephalopathy and seizures are typical in PRES. In PRES, brain imaging shows reversible vasogenic edema that is typically symmetric and located in subcortical regions (mostly posterior predominant). In RCVS, brain imaging is often normal; cerebral angiography shows segmental vasoconstriction-vasodilatation affecting the circle of Willis arteries and their branches. Aside from shared clinical features, significant imaging overlap exists. Both PRES and RCVS can be complicated by ischemic and hemorrhagic brain lesions; angiographic abnormalities frequently occur in PRES and vasogenic edematous lesions in RCVS. Common triggers (eg, eclampsia, vasoconstrictive and chemotherapeutic agents) have been identified. Abnormal cerebrovascular tone and endothelial dysfunction may explain both syndromes. Management of these syndromes includes the removal of identified triggers, symptomatic treatment of headache or seizures, and moderate blood pressure control. Both syndromes are self-limited, with clinical recovery occurring within days to weeks. Long-term deficits and mortality are uncommon. SUMMARY PRES and RCVS have been well characterized and acknowledged to have significant overlap. Advances in our understanding of pathophysiology and risk factors for poor outcome are expected to optimize the management of these not uncommon syndromes.
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26
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Clinical Presentation and Risk Factors for Poor Outcomes Among Adult Patients With Posterior Reversible Encephalopathy Syndrome: A Retrospective Cohort Study. Neurologist 2021; 25:162-167. [PMID: 33181724 DOI: 10.1097/nrl.0000000000000294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is an acute neurological condition with unknown global incidence, variable clinical presentation, and prognosis. OBJECTIVES To describe a cohort of patients with PRES with a focus on brain magnetic resonance imaging (MRI) patterns and their relationship with short-term clinical outcomes. METHODS Retrospective cohort study. The authors included patients if they were older than 15 years and had a PRES diagnosis on the basis of a positive brain MRI at any time during the in-hospital stay. RESULTS Forty-four patients were included in the present analysis. The median age was 57 years (interquartile range, 32.0-68.5) and 70.5% were women. Hypertension (59.1%), history of transplantation (27.3%), previous chemotherapy (27.3%), chronic renal failure (38.6%), and autoimmune disease (15%) were the main comorbid conditions present. The classic triad of seizures, headache, and visual impairment was present in 18.0% of the cases. Eighty-six percent of patients were admitted to the intensive care unit, with 36.0% needing invasive life support. Brain MRI showed a dominant parieto-occipital pattern in 26 patients, whereas cytotoxic edema and bleeding were present in 27.3% and 29.6%, respectively. In-hospital mortality was 11.4%. The median modified Rankin Scale at hospital discharge was 1 (0-2.5). Risk factors associated with low modified Rankin Scale scores were: headache, visual impairment, and parieto-occipital pattern. Decreased level of consciousness and mechanical ventilation requirement were associated with greater discharge disability. CONCLUSIONS Characteristic symptoms and signs of PRES and classic MRI patterns are associated with better clinical outcomes.
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27
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Navarro-Ballester A, Revert-Espí R. Unusual Presentation of a Posterior Reversible Encephalopathy Syndrome With Brainstem Involvement and Subarachnoid Haemorrhage. Cureus 2021; 13:e16295. [PMID: 34381653 PMCID: PMC8351525 DOI: 10.7759/cureus.16295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2021] [Indexed: 11/30/2022] Open
Abstract
Posterior reversible encephalopathy syndrome is an increasingly recognized disorder characterized by a headache, visual disturbances, and seizures. It is a reversible neurotoxic state, with multiple risk factors in which endothelial injury and compromised brain perfusion are the common characteristics. Diagnosis is usually made by cerebral magnetic resonance imaging that typically shows early-stage bilateral symmetrical parieto-occipital hyperintensities on T2 and fluid-attenuated inversion recovery (FLAIR) sequences. However, other locations have been described where the disease may appear less frequently. We describe the case of a 62-year-old man, with a medical history of hypertension, who presented with anisocoria with mydriatic non-reactive pupil and ptosis of the left eye. CT head showed a slightly hypodense brainstem, in relation to vasogenic edema. This was confirmed with magnetic resonance imaging. The angiography did not identify cerebral artery aneurysms. The symptoms and radiological findings were almost completely reversible after improving the patient's blood pressure. This case highlights a rare single presentation of posterior reversible encephalopathy syndrome associated with subarachnoid hemorrhage. A high index of suspicion, careful examination, and exploration with imaging techniques were essential to reach this diagnosis.
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Affiliation(s)
| | - Rafael Revert-Espí
- Radiology Department, Hospital General Universitario de Castellón, Castellón de la Plana, ESP
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28
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El Hage S, Akiki D, Khalife L, Assaf E, Jaoude MA. Rapid clinical recovery of posterior reversible encephalopathy syndrome in two cases of IgA nephropathy disease and nephrotic syndrome type 9 post-renal transplant. Transpl Immunol 2021; 68:101450. [PMID: 34391883 DOI: 10.1016/j.trim.2021.101450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 11/28/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological syndrome often associated with immunosuppressant drug use, renal disease, and eclampsia and characterized by parieto-occipital vasogenic edema that usually resolves within days. Globally and in the settings of renal transplant, literature concerning PRES is very scattered. In this report, we provide two cases, one diagnosed with IgA nephropathy and another with nephrotic syndrome type 9 that developed episodes of tonic-clonic seizure immediately after renal transplant in case 1 and four days post-transplant in case 2. The two patients had a history of hypertension, renal disease, corticosteroid and immunosuppressant drug use. Neuro-imaging showed typical vasogenic edema involving the parieto-occipital areas. Therefore, the clinical-radiological presentation confirmed the diagnosis of PRES in both cases. Also, rapid neurologic recovery was witnessed upon administration of anti-epileptic and anti-hypertensive medications. Non-discontinuation of immunosuppressants, steroids, early symptomatic management, and blood pressure control are favorable factors that might explain the rapid recovery of these two patients.
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Affiliation(s)
- Said El Hage
- Lebanese University, Faculty of Medical Sciences, Department of Medicine, Beirut, Lebanon; Lebanese University, Faculty of Medical Sciences, Neuroscience Research Center, Beirut, Lebanon; Institut National de Santé Publique, Epidémiologie Clinique et Toxicologie, Sector of Public Health and Epidemiology, Department of Public Health, Beirut, Lebanon
| | - Dany Akiki
- Lebanese University, Faculty of Medical Sciences, Department of Medicine, Beirut, Lebanon.
| | - Lourdes Khalife
- Department of Neurology, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Elie Assaf
- Department of Neurology, Middle East Institute of Health, Bsalim, Lebanon
| | - Maroun Abou Jaoude
- Transplantation Unit, Department of General Surgery, Middle East Institute of Health, Bsalim, Lebanon; Department of General Surgery, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
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29
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Dashti-Khavidaki S, Moghadamnia M, Jafarian A, Chavoshi-Khamneh A, Moradi A, Ahmadinejad Z, Ghiasvand F, Tasa D, Nasiri-Toosi M, Taher M. Thrombotic Microangiopathy, Antibody-Mediated Rejection, and Posterior Reversible Leukoencephalopathy Syndrome in a Liver Transplant Recipient: Interplay Between COVID-19 and Its Treatment Modalities. EXP CLIN TRANSPLANT 2021; 19:990-993. [PMID: 34269648 DOI: 10.6002/ect.2021.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The present COVID-19 pandemic is a cause for concern among solid-organ transplant recipients, who are generally at high risk for infection and for whom infection with COVID-19 carries additional risks for complications and mortality that are higher than the COVID-19-associated risks for the general population. We report the case of a liver transplant recipient who presented with COVID-19 and multiple complications. A 39-year-old woman with a liver transplant was diagnosed with COVID-19 within the first week after transplant surgery. Mycophenolate was withheld, and interferon β was administered for management of COVID-19. She developed thrombotic thrombocytopenic purpura, acute antibody-mediated rejection, and posterior reversible leukoencephalopathy syndrome during hospitalization. All of these complications may be related to COVID-19 or its management modalities. We considered 3 possible causes for thrombotic thrombocytopenic purpura in this patient: the COVID-19 infection itself, immunosuppression treatment with cyclosporine, and treatment with interferon β. Immunosuppression reduction and interferon treatment may result in antibody-mediated rejection. COVID-19, thrombotic thrombocytopenic purpura, and cyclosporine may play a combined role in the development of posterior reversible leukoencephalopathy syndrome. In conclusion, thrombotic thrombocytopenic purpura, antibody-mediated rejection, and posterior reversible leukoencephalopathy syndrome may represent a continuum of 3 thrombotic microangiopathy conditions fostered by interplay between the COVID-19 infection and the treatment modalities for COVID-19 management in this patient.
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Affiliation(s)
- Simin Dashti-Khavidaki
- From the Department of Pharmacotherapy, Liver Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
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30
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Steriade C, Titulaer MJ, Vezzani A, Sander JW, Thijs RD. The association between systemic autoimmune disorders and epilepsy and its clinical implications. Brain 2021; 144:372-390. [PMID: 33221878 DOI: 10.1093/brain/awaa362] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 08/03/2020] [Accepted: 08/13/2020] [Indexed: 12/12/2022] Open
Abstract
Systemic autoimmune disorders occur more frequently in patients with epilepsy than in the general population, suggesting shared disease mechanisms. The risk of epilepsy is elevated across the spectrum of systemic autoimmune disorders but is highest in systemic lupus erythematosus and type 1 diabetes mellitus. Vascular and metabolic factors are the most important mediators between systemic autoimmune disorders and epilepsy. Systemic immune dysfunction can also affect neuronal excitability, not only through innate immune activation and blood-brain barrier dysfunction in most epilepsies but also adaptive immunity in autoimmune encephalitis. The presence of systemic autoimmune disorders in subjects with acute seizures warrants evaluation for infectious, vascular, toxic and metabolic causes of acute symptomatic seizures, but clinical signs of autoimmune encephalitis should not be missed. Immunosuppressive medications may have antiseizure properties and trigger certain drug interactions with antiseizure treatments. A better understanding of mechanisms underlying the co-existence of epilepsy and systemic autoimmune disorders is needed to guide new antiseizure and anti-epileptogenic treatments. This review aims to summarize the epidemiological evidence for systemic autoimmune disorders as comorbidities of epilepsy, explore potential immune and non-immune mechanisms, and provide practical implications on diagnostic and therapeutic approach to epilepsy in those with comorbid systemic autoimmune disorders.
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Affiliation(s)
- Claude Steriade
- Department of Neurology, New York University School of Medicine, New York, NY, USA
| | - Maarten J Titulaer
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Annamaria Vezzani
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Josemir W Sander
- NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK.,Chalfont Centre for Epilepsy, Chalfont St Peter SL9 0RJ, Bucks, UK.,Stichting Epilepsie Instellingen Nederland - (SEIN), Heemstede, The Netherlands
| | - Roland D Thijs
- NIHR University College London Hospitals Biomedical Research Centre, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK.,Stichting Epilepsie Instellingen Nederland - (SEIN), Heemstede, The Netherlands.,Department of Neurology, Leiden University Medical Centre, Leiden, The Netherlands
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31
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Faravelli I, Velardo D, Podestà MA, Ponticelli C. Immunosuppression-related neurological disorders in kidney transplantation. J Nephrol 2021; 34:539-555. [PMID: 33481222 PMCID: PMC8036223 DOI: 10.1007/s40620-020-00956-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/27/2020] [Indexed: 01/06/2023]
Abstract
A large number of neurological disorders can affect renal transplant recipients, potentially leading to disabling or life-threatening complications. Prevention, early diagnosis and appropriate management of these conditions are critical to avoid irreversible lesions. A pivotal role in the pathogenesis of common post-transplant neurological disorders is played by immunosuppressive therapy. The most frequently administered regimen consists of triple immunosuppression, which comprises a calcineurin inhibitor (CNI), a purine synthesis inhibitor and glucocorticoids. Some of these immunosuppressive drugs may lead to neurological signs and symptoms through direct neurotoxic effects, and all of them may be responsible for the development of tumors or opportunistic infections. In this review, after a brief summary of neurotoxic pathogenetic mechanisms encompassing recent advances in the field, we focus on the clinical presentation of more common and severe immunosuppression-related neurological complications, classifying them by characteristics of urgency and anatomic site. Our goal is to provide a general framework that addresses such clinical issues with a multidisciplinary approach, as these conditions require.
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Affiliation(s)
- Irene Faravelli
- Neuroscience Section, Department of Pathophysiology and Transplantation (DEPT), Dino Ferrari Centre, Università degli Studi di Milano, Milan, Italy.
| | - Daniele Velardo
- Neurology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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32
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Angermann M, Jablawi F, Keulers A, Angermann M, Schubert GA, Weiss M, Reich A, Wiesmann M, Nikoubashman O. Posterior reversible encephalopathy syndrome after induced hypertension therapy for delayed cerebral ischemia after subarachnoid hemorrhage: A case-control study. J Neurol Sci 2021; 421:117313. [PMID: 33461062 DOI: 10.1016/j.jns.2021.117313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is associated with arterial hypertension. Our aim was to investigate whether induced hypertension (IH) as therapy for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is associated with PRES and to identify risk factors for PRES. MATERIAL AND METHODS We retrospectively searched our database for patients with SAH and IH in our institution between 2009 and 2018 and identified additional cases of PRES after SAH with IH from the literature. We then analyzed demographic findings and clinical features of these patients. RESULTS 172 patients with acute SAH received IH. PRES was diagnosed in 3/172 (1.7%) patients. Our literature search revealed 17 additional cases. The pooled PRES group (n = 20) was non-significantly older than the non-PRES group (n = 169) (median, 62.5 years vs. 52 years, p = 0.06). No significant differences were found between both groups with regard to sex (p = 0.73), Hunt & Hess-Score (p = 0.9), aneurysm treatment (p = 0.13), and time from diagnosis of SAH to the start of IH (p = 0.14). CONCLUSIONS PRES after IH in SAH patients occurred in 1.7% of our patients. Our results imply that it is important to be aware of a possible development of a PRES in older SAH patients with IH, irrespective of sex, initial clinical status, and treatment modality.
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Affiliation(s)
- Maike Angermann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Fidaa Jablawi
- Department of Neurosurgery, Justus-Liebig-University Gießen, Germany
| | - Annika Keulers
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Manuel Angermann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, University Hospital RWTH, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, University Hospital RWTH, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany.
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Coe CL, Horst SN, Izzy MJ. Neurologic Toxicities Associated with Tumor Necrosis Factor Inhibitors and Calcineurin Inhibitors. Neurol Clin 2020; 38:937-951. [PMID: 33040870 DOI: 10.1016/j.ncl.2020.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The calcineurin inhibitors cyclosporine and tacrolimus are used for their immunosuppressive effects. Neurotoxic side effects include tremor, paresthesia, and headache. Rarer neurotoxicities include seizure, posterior reversible encephalopathy syndrome, and encephalopathy. Tacrolimus tends to be more neurotoxic than cyclosporine. Management of toxicities associated with calcineurin inhibitors includes dose reduction, switching between calcineurin inhibitors, or switching to a calcineurin-free regimen. Tumor necrosis factor (TNF) inhibitors are used in autoimmune diseases. Management of demyelinating conditions among patients treated with anti-TNF should follow standard of care and withdrawal of the anti-TNF. This drug class should be avoided in patients with a history of demyelinating conditions.
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Affiliation(s)
- Christopher L Coe
- Department of Medicine, Section of Hospital Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN 37232, USA. https://twitter.com/ccoemd
| | - Sarah N Horst
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1211 21st Avenue South, Medical Arts Building, Suite 220, Nashville, TN 37232, USA. https://twitter.com/HorstIBDDoc
| | - Manhal J Izzy
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Transplant Hepatology, 1660 The Vanderbilt Clinic, Nashville, TN 37232, USA.
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Posterior Reversible Encephalopathy Syndrome after Allogeneic Stem Cell Transplantation in Pediatric Patients with Fanconi Anemia, a Prospective Study. Biol Blood Marrow Transplant 2020; 26:e316-e321. [PMID: 32860910 DOI: 10.1016/j.bbmt.2020.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/20/2020] [Accepted: 08/16/2020] [Indexed: 12/15/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is one of the most common neurologic complications following hematopoietic stem cell transplantation (HSCT). We aimed to evaluate the incidence, clinical, and imaging features of PRES in pediatric patients with Fanconi anemia (FA) following HSCT. This prospective study included all post-HSCT patients with underlying FA disease between 2014 and 2017. Brain computed tomography scan and magnetic resonance imaging (MRI) were performed in all individuals who developed neurologic symptoms. PRES was diagnosed based on clinic-radiological evidence. Follow-up MRI was performed in all patients with PRES within two months. Forty-one patients with FA (28 males; mean age, 8.19 ± 3.25 years) were enrolled. Out of 15 patients with acute neurologic symptoms, PRES was diagnosed in 9 individuals (21.95% of the total cohort). The occurrence of PRES was significantly higher in patients who had a donor with a 1-locus mismatch (P= .02). Donor relation, stem cell source, and graft-versus-host disease grade did not have any significant association with the development of PRES. MRI showed asymmetric vasogenic edema in 5 patients, an overt infarct in 1 patient, and foci of microhemorrhages in 3 patients, 1 of whom developed a hemorrhagic infarct. This patient died shortly, and persistent microhemorrhages were noted in the other 2 patients. Our findings demonstrate a greater risk of developing PRES after HSCT in patients with FA compared with those with other diseases (21.95% versus 1% to 10%), and in contrast to its term, it might be irreversible and has adverse effects on HSCT outcomes. The increased vascular and endothelial fragility in FA may contribute to the higher frequency of PRES in these individuals.
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Liu JF, Shen T, Zhang YT. Posterior reversible encephalopathy syndrome and heart failure tacrolimus-induced after liver transplantation: A case report. World J Clin Cases 2020; 8:2870-2875. [PMID: 32742997 PMCID: PMC7360704 DOI: 10.12998/wjcc.v8.i13.2870] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 05/07/2020] [Accepted: 06/13/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients undergoing liver transplantation can develop posterior reversible encephalopathy syndrome (PRES) and acute heart failure (HF) in the post-operative period. But PRES with HF caused by tacrolimus has rarely been described.
CASE SUMMAR A 40-year-old female patient who had a normal preoperative cardiac and neural evaluation developed PRES with acute heart failure tacrolimus-induced after liver transplantation. The challenges associated with both diagnosis and management in the setting of a newly implanted graft are discussed.
CONCLUSION Tacrolimus can induce neurotoxicity and then cardiac toxicity. Magnetic resonance imaging, echocardiography, and increased brain natriuretic peptide may be predictive of post-operative PRES with acute heart failure. Further investigations are necessary to verify this finding.
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Affiliation(s)
- Jun-Fang Liu
- Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Tian Shen
- Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
| | - Yun-Tao Zhang
- Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310003, Zhejiang Province, China
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Ghaffari-Rafi A, Netzel AC, Prat M, Miles DT. Cerebellar Parieto-occipital Posterior Reversible Encephalopathy Syndrome and Cerebral Metamorphopsia Associated with Asymptomatic Atrial Septum Vegetation and Renal Disease: Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923441. [PMID: 32516303 PMCID: PMC7304656 DOI: 10.12659/ajcr.923441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patient: Female, 25-year-old Final Diagnosis: Posterior reversible encephalopathy syndrome Symptoms: Visual disturbances Medication: — Clinical Procedure: — Specialty: Neurology
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Affiliation(s)
- Arash Ghaffari-Rafi
- Queen Square Institute of Neurology, University College London, London, United Kingdom.,John A. Burns School of Medicine, University of Hawaii at Mānoa, Honolulu, HI, USA
| | - Anthony C Netzel
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI, USA
| | - Madeline Prat
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI, USA
| | - Daniel T Miles
- Department of Medicine, Tripler Army Medical Center, Honolulu, HI, USA
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Posteriores reversibles enzephalopathisches Syndrom und Hyperammonämie: zwei Entitäten für Hirnödem und Status epilepticus bei einer Patientin nach Lungentransplantation. Anaesthesist 2020; 69:506-513. [DOI: 10.1007/s00101-020-00771-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/27/2020] [Accepted: 03/16/2020] [Indexed: 12/13/2022]
Abstract
ZusammenfassungFünf Wochen nach primär erfolgreicher Lungentransplantation entwickelt eine 58-jährige Patientin rasch progrediente neurologische Symptome mit Vigilanzverlust. Als Ursachen können einerseits ein posteriores reversibles enzephalopathisches Syndrom (PRES) unter Therapie mit Tacrolimus, andererseits eine schwere Hyperammonämie durch Sepsis mit Ureaplasma urealyticum identifiziert werden. Infektionen mit Ureaplasmen, die Ammoniak als Stoffwechselprodukt produzieren, werden durch spezifische „polymerase chain reaction“(PCR, Polymerase Kettenreaktion)-Verfahren zunehmend bei Immunsupprimierten identifiziert und sollten grundsätzlich als Ursache für unklare neurologische Symptome in Betracht gezogen werden.
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Ghali MGZ, Styler MJ. Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients. JOURNAL OF PEDIATRIC NEUROLOGY 2020. [DOI: 10.1055/s-0040-1702934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractThe posterior reversible encephalopathy syndrome was characterized by Hinchey and colleagues in the 1990s. The condition frequently afflicts patients suffering from hematologic and solid organ malignancy and individuals undergoing transplantation. Cases are more frequently described in the adult population compared with children. In the pediatric population, malignancy, transplantation, renal disease, and hypertension represent the most common etiologies. Theories on pathogenesis have centered upon cerebrovascular dysautoregulation with increases in blood–brain barrier permeability. This generates vasogenic edema of the cerebral parenchyma and consequent neurologic deficits. The parietal and occipital lobes are affected with greatest prevalence, though frontal and temporal lobe involvement is frequent, and that of the contents of the infratentorial posterior cranial fossa are occasionally described. The clinical presentation involves a characteristic constellation of neurologic signs and symptoms, most typically inclusive of headache, visual-field disturbances, abnormalities of visual acuity, and seizures. Supportive care, withdrawal of the offending agent, antihypertensive therapy, and prophylactic anticonvulsants affect convalescence in majority of cases. The principal challenge lies in identifying the responsible agent precipitating the condition in patients with malignancy and those having undergone transplantation and thus deciding which medication among a multidrug treatment regimen to withhold, the duration of drug cessation required to effect clinical resolution, and the safety of resuming treatment with the compound. We accordingly reviewed and evaluated the literature discussing the posterior reversible encephalopathy syndrome in children.
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Affiliation(s)
- Michael G. Z. Ghali
- Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, United States
| | - Michael J. Styler
- Department of Hematology and Oncology, Hahnemann University Hospital, Philadelphia, Pennsylvania, United States
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Hinduja A. Posterior Reversible Encephalopathy Syndrome: Clinical Features and Outcome. Front Neurol 2020; 11:71. [PMID: 32117030 PMCID: PMC7034490 DOI: 10.3389/fneur.2020.00071] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/21/2020] [Indexed: 01/24/2023] Open
Abstract
Background: Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that is characterized by a spectrum neurological and radiological feature from various risk factors. Common neurological symptoms includes headache, impairment in level of consciousness, seizures, visual disturbances, and focal neurological deficits. Common triggering factors include blood pressure fluctuations, renal failure, eclampsia, exposure to immunosuppressive or cytotoxic agents and autoimmune disorders. The classic radiographic findings include bilateral subcortical vasogenic edema predominantly affecting the parieto-occipital regions but atypical features include involvement of other regions, cortical involvement, restricted diffusion, hemorrhage, contrast enhancement. This review is aimed to summarize the updated knowledge on the typical and atypical clinical and imaging features, prognostic markers and identify gaps in literature for future research. Methods: Systematic literature review using PUBMED search from 1990 to 2019 was performed using terms PRES was performed. Results: While clinical and radiographic reversibility is common, long-standing morbidity and mortality can occur in severe forms. In patients with malignant forms of PRES, aggressive care has markedly reduced mortality and improved functional outcomes. Although seizures were common, epilepsy is rare. Various factors that have been associated with poor outcome include altered sensorium, hypertensive etiology, hyperglycemia, longer time to control the causative factor, elevated C reactive protein, coagulopathy, extensive cerebral edema, and hemorrhage on imaging. Conclusion: Large prospective studies that accurately predict factors that are associated with poor outcomes, determine the pathophysiology, and targeted therapy are required.
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Affiliation(s)
- Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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40
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Molema F, Williams M, Langendonk J, Darwish-Murad S, van de Wetering J, Jacobs E, Onkenhout W, Brusse E, van der Eerden A, Wagenmakers M. Neurotoxicity including posterior reversible encephalopathy syndrome after initiation of calcineurin inhibitors in transplanted methylmalonic acidemia patients: Two case reports and review of the literature. JIMD Rep 2020; 51:89-104. [PMID: 32071844 PMCID: PMC7012740 DOI: 10.1002/jmd2.12088] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 10/15/2019] [Accepted: 11/15/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction New neurological symptoms in methylmalonic acidemia (MMA) patients after liver and/or kidney transplantation (LKT) are often described as metabolic stroke‐like‐events. Since calcineurin inhibitors (CNIs) are a well‐known cause of new neurological symptoms in non‐MMA transplanted patients, we investigated the incidence of CNI‐induced neurotoxicity including posterior reversible encephalopathy syndrome (PRES) in post‐transplanted MMA patients. Methods We report the two MMA patients treated with LKT in our center. Additionally, we performed a systematic review of case reports/series of post‐transplanted MMA patients and determined if CNI‐induced neurotoxicity/PRES was a likely cause of new neurological symptoms. Definite CNI‐induced neurotoxicity was defined as new neurological symptoms during CNI treatment with symptom improvement after CNI dose reduction/discontinuation. PRES was defined as CNI‐induced neurotoxicity with signs of vasogenic edema on brain magnetic resonance imaging (MRI)‐scan post‐transplantation. Results Our two MMA patients both developed CNI‐induced neurotoxicity, one had PRES. In literature, 230 transplanted MMA patients were identified. Neurological follow‐up was reported in 54 of them, of which 24 were excluded from analysis since no anti‐rejection medication was reported. Thirty patients, all using CNI, were included. Sixteen patients (53%) had no new neurological symptoms post‐transplantation and five patients (17%) had definite CNI neurotoxicity of whom two had PRES. Including our cases this results in a pooled incidence of 22% (7/32) definite CNI neurotoxicity and 9% PRES (3/32) in post‐transplanted MMA patients on CNI. Conclusion In MMA post‐transplanted patients with new neurological symptoms CNI‐induced neurotoxicity/PRES should be considered. Early recognition of CNI‐induced neurotoxicity is essential to initiate dose reduction/discontinuation of CNI to minimize persistent neurologic damage and improve outcome. Concise one sentence take home message In all post‐transplanted MMA patients with new neurological symptoms CNI‐induced neurotoxicity/PRES should be considered, and directly reducing the dose/discontinuation of CNI is essential.
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Affiliation(s)
- Femke Molema
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands
| | - Monique Williams
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands
| | - Janneke Langendonk
- Department of Internal Medicine, Erasmus University Medical Center Center for Lysosomal and Metabolic Disease Rotterdam The Netherlands
| | - Sarwa Darwish-Murad
- Department of Gastroenterology and Hepatology Erasmus University Medical Center Rotterdam The Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine Erasmus University Medical Center, Nephrology and Transplantation, Rotterdam Transplant Group Rotterdam The Netherlands
| | - Ed Jacobs
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands.,Department of Clinical Genetics Erasmus University Medical Center Rotterdam The Netherlands
| | - Willem Onkenhout
- Department of Pediatrics, Center for Lysosomal and Metabolic Disease Erasmus - Sophia Children's Hospital, University Medical Center Rotterdam The Netherlands.,Department of Clinical Genetics Erasmus University Medical Center Rotterdam The Netherlands
| | - Esther Brusse
- Department of Neurology Erasmus University Medical Center Rotterdam The Netherlands
| | - Anke van der Eerden
- Department of Radiology Erasmus University Medical Center Rotterdam The Netherlands
| | - Margreet Wagenmakers
- Department of Internal Medicine, Erasmus University Medical Center Center for Lysosomal and Metabolic Disease Rotterdam The Netherlands
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Posterior reversible encephalopathy syndrome (PRES): Is DWI a prognosis factor? J Clin Neurosci 2019; 72:357-359. [PMID: 31874813 DOI: 10.1016/j.jocn.2019.12.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 12/01/2019] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Posterior reversible encephalopathy syndrome is a clinicoradiologic entity with typical MR imaging showing a white matter vasogenic edema predominantly affecting the occipital and parietal lobes of the brain. The aim of this article is evaluated the importance of DWI as a prognosis factor in patients with PRES. MATERIALS AND METHODS We reviewed data from 70 patients with PRES (35 with restricted DWI and 35 with no DWI abnormalities), that were admitted to Hospital São Lucas-PUCRS. These two groups were evaluated in age, sex, previous diseases and past medical history, use of medications, the neurologic manifestations, the highest blood pressure during the neurologic presentation and the highest creatinine during the period of observation. RESULTS Evaluating 70 patients with PRES with a mean age of 25.4 years old (range from 2 to 74 years old; 55 female and 15 male) we identified 35 cases were brain MRI presents with restricted DWI. Restricted DWI was associated with higher mortality in 90 days (14.2% vs 0.0%; p: 0.027). CONCLUSIONS Few articles present new data that will help clinicians in therapeutic decisions or that modify the knowledge of this syndrome. We suggested that restricted DWI is associated with a worst prognosis in PRES.
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Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome: Distinct Clinical Entities with Overlapping Pathophysiology. Radiol Clin North Am 2019; 57:1133-1146. [PMID: 31582040 DOI: 10.1016/j.rcl.2019.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The clinical and radiologic manifestations of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome are reviewed. The relationship between these entities is discussed. A hypothesis of a common underlying pathophysiology is proposed and substantiated based on the current medical literature.
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Abstract
Neurologic disturbances including encephalopathy, seizures, and focal deficits complicate the course 10-30% of patients undergoing organ or stem cell transplantation. While much or this morbidity is multifactorial and often associated with extra-cerebral dysfunction (e.g., graft dysfunction, metabolic derangements), immunosuppressive drugs also contribute significantly. This can either be through direct toxicity (e.g., posterior reversible encephalopathy syndrome from calcineurin inhibitors such as tacrolimus in the acute postoperative period) or by facilitating opportunistic infections in the months after transplantation. Other neurologic syndromes such as akinetic mutism and osmotic demyelination may also occur. While much of this neurologic dysfunction may be reversible if related to metabolic factors or drug toxicity (and the etiology is recognized and reversed), cases of multifocal cerebral infarction, hemorrhage, or infection may have poor outcomes. As transplant patients survive longer, delayed infections (such as progressive multifocal leukoencephalopathy) and post-transplant malignancies are increasingly reported.
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Ghali MGZ, Davanzo J, Leo M, Rizk E. Posterior reversible encephalopathy syndrome in pediatric patients: pathophysiology, diagnosis, and management. Leuk Lymphoma 2019; 60:2365-2372. [PMID: 31556774 DOI: 10.1080/10428194.2019.1594210] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is well-described in adults, but has been reported with relative rarity in children, usually occurring in the context of chemotherapy for acute leukemia. Pathogenesis involves perturbed cerebral autoregulation leading to vasogenic edema predominantly affecting the parieto-occipital white matter, though involvement of the frontal and temporal lobes, as well as posterior fossa, is also described. We review the literature on the pathophysiology, diagnosis, and management of PRES in pediatric patients.
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Affiliation(s)
- Michael G Z Ghali
- Department of Neurological Surgery, Houston Methodist Hospital , Houston , TX , USA.,Department of Neurological Surgery, Penn State Hershey Medical Center , Hershey , PA , USA
| | - Justin Davanzo
- Department of Neurological Surgery, Penn State Hershey Medical Center , Hershey , PA , USA
| | - Madeline Leo
- Department of Neurological Surgery, Penn State Hershey Medical Center , Hershey , PA , USA
| | - Elias Rizk
- Department of Neurological Surgery, Penn State Hershey Medical Center , Hershey , PA , USA
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Acar S, Kavlak ME, Demir B, Ozkan P, Polat KY, Akyildiz M, Arikan C. Posterior Reversible Encephalopathy Syndrome in a Five-Year-Old Child: A Case Report. Transplant Proc 2019; 51:2495-2497. [PMID: 31351771 DOI: 10.1016/j.transproceed.2019.01.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/28/2019] [Indexed: 10/26/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neuroradiologic syndrome. The etiology of PRES is still unclear. Some factors were described. We present a case of a pediatric patient with liver transplant who developed PRES following blood transfusion while receiving tacrolimus therapy. A 5½-year-old boy who underwent living donor liver transplantation, and PRES developed on the sixth day post transplant under tacrolimus treatment after 6 hours of red blood transfusion. PRES is a rare condition; it should be kept in mind about patients who have received organ transplants and develop sudden neurologic symptoms.
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Affiliation(s)
- Sencan Acar
- Department of Gastroenterology and Organ Transplant Center, Sakarya University School of Medicine, Sakarya, Turkey.
| | - Mustafa Emre Kavlak
- Department of Anesthesiology and Organ Transplant Center, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Baris Demir
- Department of Family Practice and Organ Transplant Center, Koc University School of Medicine, Istanbul, Turkey
| | - Perihan Ozkan
- Department of Radiology, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Kamil Yalcin Polat
- Department of General Surgery and Organ Transplant Center, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Murat Akyildiz
- Department of Gastroenterology and Organ Transplant Center, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Cigdem Arikan
- Department of Pediatric Gastroenterology and Organ Transplant Center, Koc University School of Medicine, Istanbul, Turkey
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Recent Topics on The Mechanisms of Immunosuppressive Therapy-Related Neurotoxicities. Int J Mol Sci 2019; 20:ijms20133210. [PMID: 31261959 PMCID: PMC6651704 DOI: 10.3390/ijms20133210] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 02/07/2023] Open
Abstract
Although transplantation procedures have been developed for patients with end-stage hepatic insufficiency or other diseases, allograft rejection still threatens patient health and lifespan. Over the last few decades, the emergence of immunosuppressive agents such as calcineurin inhibitors (CNIs) and mammalian target of rapamycin (mTOR) inhibitors have strikingly increased graft survival. Unfortunately, immunosuppressive agent-related neurotoxicity commonly occurs in clinical practice, with the majority of neurotoxicity cases caused by CNIs. The possible mechanisms through which CNIs cause neurotoxicity include increasing the permeability or injury of the blood–brain barrier, alterations of mitochondrial function, and alterations in the electrophysiological state. Other immunosuppressants can also induce neuropsychiatric complications. For example, mTOR inhibitors induce seizures, mycophenolate mofetil induces depression and headaches, methotrexate affects the central nervous system, the mouse monoclonal immunoglobulin G2 antibody (used against the cluster of differentiation 3) also induces headaches, and patients using corticosteroids usually experience cognitive alteration. Therapeutic drug monitoring, individual therapy based on pharmacogenetics, and early recognition of symptoms help reduce neurotoxic events considerably. Once neurotoxicity occurs, a reduction in the drug dosage, switching to other immunosuppressants, combination therapy with drugs used to treat the neuropsychiatric manifestation, or blood purification therapy have proven to be effective against neurotoxicity. In this review, we summarize recent topics on the mechanisms of immunosuppressive drug-related neurotoxicity. In addition, information about the neuroprotective effects of several immunosuppressants is also discussed.
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Abstract
Renal transplant is the most common organ transplant in the United States, and the frequency of kidney transplants continues to rise as transplant offers improved survival and quality of life compared to dialysis. However, complications are not uncommon and patients frequently encounter issues requiring hospitalization, especially in the first year postoperatively. Complications that arise are typically related to surgical complications, immunosuppressive medications, or infection due to immunosuppression. Neurological complications are fairly common post-operatively, and are associated with increased morbidity and mortality in this population. This review discusses the most common etiologies of neurological complications after kidney transplant, including infection, malignancy, medication related, acute neuropathy, and other neurological pathology.
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Largeau B, Le Tilly O, Sautenet B, Salmon Gandonnière C, Barin-Le Guellec C, Ehrmann S. Arginine Vasopressin and Posterior Reversible Encephalopathy Syndrome Pathophysiology: the Missing Link? Mol Neurobiol 2019; 56:6792-6806. [PMID: 30924075 DOI: 10.1007/s12035-019-1553-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 03/13/2019] [Indexed: 12/12/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinicoradiological entity characterized by a typical brain edema. Its pathogenesis is still debated through hypoperfusion and hyperperfusion theories, which have many limitations. As PRES occurs almost exclusively in clinical situations with arginine vasopressin (AVP) hypersecretion, such as eclampsia and sepsis, we hypothesize that AVP plays a central pathophysiologic role. In this review, we discuss the genesis of PRES and its symptoms through this novel approach. We theorize that AVP axis stimulation precipitates PRES development through an increase in AVP secretion or AVP receptor density. Activation of vasopressin V1a receptors leads to cerebral vasoconstriction, causing endothelial dysfunction and cerebral ischemia. This promotes cytotoxic edema through hydromineral transglial flux dysfunction and may increase endothelial permeability, leading to subsequent vasogenic brain edema. If our hypothesis is confirmed, it opens new perspectives for better patient monitoring and therapies targeting the AVP axis in PRES.
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Affiliation(s)
- Bérenger Largeau
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France.
| | - Olivier Le Tilly
- CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Bénédicte Sautenet
- Université de Tours, Université de Nantes, INSERM, Methods in patients-centered outcomes and health research (SPHERE) - UMR 1246, CHRU de Tours, Service de Néphrologie-Hypertension artérielle, Dialyses et Transplantation Rénale, Tours, France
| | | | - Chantal Barin-Le Guellec
- Université de Tours, Université de Limoges, INSERM, Individual profiling and prevention of risks with immunosuppressive therapies and transplantation (IPPRITT) - UMR 1248, CHRU de Tours, Laboratoire de Biochimie et Biologie Moléculaire, Tours, France
| | - Stephan Ehrmann
- Université de Tours, INSERM, Centre d'étude des pathologies respiratoires (CEPR) - UMR 1100, CHRU de Tours, Service de Médecine Intensive Réanimation, CIC 1415, réseau CRICS-TRIGGERSEP, Tours, France
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Tseng WC, Lai HC, Yeh CC, Fan HL, Wu ZF. Overdose of Tacrolimus as the Trigger Causing Progression of Posterior Reversible Encephalopathy Syndrome and Subsequent Hepatic Infarction After Liver Transplant: A Case Report. EXP CLIN TRANSPLANT 2018; 18:128-132. [PMID: 30602365 DOI: 10.6002/ect.2017.0255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Posterior reversible encephalopathy syndrome is a neurotoxic state accompanied by unique brain imaging patterns and neurologic abnormalities, typically associated with several complex clinical conditions such as preeclampsia/eclampsia, solid-organ transplant procedures, autoimmune diseases, and immunosuppressive agents. The detailed mechanism of posterior reversible encephalopathy syndrome is not known, and the current therapy is only supportive care. Here, we present a 33-year-old parturient woman with preeclampsia complicated with hemolysis, elevated liver enzymes, and low platelet syndrome, fulminant hepatitis B, acute fatty liver, and posterior reversible encephalopathy syndrome. The patient developed gross hepatic infarction soon after liver transplant. After several possible causes were excluded, we found that progression of underlying posterior reversible encephalopathy syndrome-induced endothelial damage by overdose of tacrolimus may have been the major cause for deteriorating hypoperfusion of the transplanted liver and fatal graft failure. In liver transplant recipients, severe posttransplant hypoperfusion of the grafted liver may result in loss of the liver allograft and even mortality. Poor control of underlying posterior reversible encephalopathy syndrome-associated endothelial damage because of tacrolimus overdose may lead to severe hypoperfusion of grafted hepatic vessels and subsequent hepatic infarction. This report highlights tacrolimus as a potential trigger of posterior reversible encephalopathy syndrome and may inform clinical decisions regarding tacrolimus administration in liver transplant recipients with preexisting or newly developed posterior reversible encephalopathy syndrome.
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Affiliation(s)
- Wei-Cheng Tseng
- From the Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
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Potter CA, Hsu L. Emergent Neuroimaging in the Oncologic and Immunosuppressed Patient. Neuroimaging Clin N Am 2018; 28:397-417. [DOI: 10.1016/j.nic.2018.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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