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Finsen SH, Tepel M, Neland M, Rittig S, Thiesson HC. Successful low-dose immunotherapy after kidney transplantation in a 10-year-old girl with Schimke immuno-osseous dysplasia. Pediatr Transplant 2023:e14495. [PMID: 37051678 DOI: 10.1111/petr.14495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 04/14/2023]
Abstract
BACKGROUND This case report highlights a successful steroid-free, low-dose immunosuppressive protocol for renal transplantation in a pediatric patient with Schimke immuno-osseous dysplasia with excellent 7-year patient and graft survival. Schimke immuno-osseous dysplasia is a rare multisystem disorder involving the kidney. Renal transplantation is a therapeutic option, but posttransplant mortality is high due to severe infections and posttransplant lymphoproliferative disease. METHODS A 10-year-old girl diagnosed with Schimke immuno-osseous dysplasia and end-stage renal disease underwent an AB0-compatible living-related kidney transplantation, with no donor-specific antibodies. Our standard immunosuppression protocol was modified due to the risk of infection. Basiliximab was used as induction therapy, and a reduced dose of mycophenolate mofetil and tacrolimus was initiated following transplantation, maintaining the patient on a low tacrolimus target (3-5 μg/L). Mycophenolate mofetil was discontinued after 8 weeks due to neutropenia and the patient was kept on tacrolimus as monotherapy. Five years posttransplant the patient developed acute onset of neurological symptoms, consisting of ataxia, lack of voluntary coordination, balance, aphasia and dysphagia, and diplopia. She recovered without neurological deficits within 6 weeks. Extensive evaluation revealed no pathology. To avoid a possible a component of tacrolimus-induced cerebral vasoconstriction, the immunosuppressive therapy was changed to everolimus. RESULTS Seven years posttransplant, the patient has experienced no serious infections, no rejections, and had excellent graft function, and no de novo donor-specific antibodies. CONCLUSIONS The present results indicate that low-dose immunosuppressive therapy after renal transplantation with low immunological risk should be considered for patients with Schimke immuno-osseous dysplasia.
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Affiliation(s)
- Stine Høyer Finsen
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Martin Tepel
- Department of Nephrology, Odense University Hospital, Odense, Denmark
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Mette Neland
- H.C. Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Søren Rittig
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Bloom J, Collins ML, Belovsky MP, Feduska E, Schofield P, Leong R, Augoustides JG, Lembrikov I, Kogan A, Frogel J, Rajkumar KP, Hicks MH, Fernando RJ. Perfusion-Dependent Focal Neurologic Deficits in a Critically Ill Heart Transplant Recipient: A Case of Tacrolimus-Associated Reversible Cerebral Vasospasm Syndrome? J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00235-5. [PMID: 37120321 DOI: 10.1053/j.jvca.2023.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 05/01/2023]
Abstract
TACROLIMUS, a mainstay of immunosuppression after orthotopic heart transplantation (OHT), is associated with a broad range of side effects. Vasoconstriction caused by tacrolimus has been proposed as a mechanism underlying common side effects such as hypertension and renal injury. Neurologic side effects attributed to tacrolimus include headaches, posterior reversible encephalopathy syndrome (PRES), or reversible cerebral vasospasm syndrome (RCVS). Six case reports have been published describing RCVS in the setting of tacrolimus administration after OHT. The authors report a case of perfusion-dependent focal neurologic deficits attributed to tacrolimus-induced RCVS in an OHT recipient.
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Affiliation(s)
- Jamie Bloom
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Mia P Belovsky
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Eric Feduska
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Ron Leong
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ilya Lembrikov
- Department of Anesthesiology, Sheba Medical Center-Tel HaShomer, Ramat Gan, Israel
| | - Alexander Kogan
- Department of Cardiac Surgery, Sheba Medical Center-Tel HaShomer, Ramat Gan, Israel
| | - Jonathan Frogel
- Department of Anesthesiology, Sheba Medical Center-Tel HaShomer, Ramat Gan, Israel
| | - Karuna Puttur Rajkumar
- Department of Anesthesiology, Cardiothoracic and Critical Care Sections, Wake Forest University School of Medicine, Winston Salem, NC
| | - Megan H Hicks
- Department of Anesthesiology, Cardiothoracic and Critical Care Sections, Wake Forest University School of Medicine, Winston Salem, NC
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Medical Center Boulevard, Winston Salem, NC.
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Shabo L, Ishaque M, Sarathy D, Kumar J, Xixis K, Park M. Pediatric Tacrolimus-Induced Reversible Cerebral Vasoconstriction Syndrome after Heart Transplantation. JOURNAL OF PEDIATRIC NEUROLOGY 2022. [DOI: 10.1055/s-0042-1745778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
AbstractReversible cerebral vasoconstriction syndrome (RCVS) is a rare post-organ transplantation complication. While uncommon, complications of post-transplant RCVS can be devastating, with sequelae including ischemic or hemorrhagic stroke and potential significant neurological morbidity. There is a paucity of literature on tacrolimus-mediated RCVS, particularly in the pediatric population. To date, only five case reports have been published, with the youngest patient being 15 years of age. We report the youngest case to date of post-heart transplant tacrolimus-induced RCVS in a 6-year-old male. The present case highlights the necessity of urgent imaging in suspected cases of RCVS, the potential diagnostic challenges surrounding the etiology of headache, the benefits of treating underlying cerebral vasospasm, and the importance of rapid discontinuation of the offending agent for the remission of symptoms and prevention of long-term sequelae.
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Affiliation(s)
- Leah Shabo
- University of Virginia School of Medicine, Charlottesville, Virginia, United States
| | - Mariam Ishaque
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, United States
| | - Danyas Sarathy
- University of Virginia School of Medicine, Charlottesville, Virginia, United States
| | - Jeyan Kumar
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, United States
| | - Kathryn Xixis
- Department of Neurology, University of Virginia, Charlottesville, Virginia, United States
| | - Min Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, United States
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Boitet R, de Gaalon S, Ducros A. Sindrome da vasocostrizione cerebrale reversibile. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)45780-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Tsukahara R, Ishida H, Narita J, Ishii R, Ozono K. Reversible cerebral vasoconstriction syndrome after heart transplantation. Pediatr Int 2021; 63:855-857. [PMID: 33963660 DOI: 10.1111/ped.14520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/01/2020] [Accepted: 10/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Rie Tsukahara
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hidekazu Ishida
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Jun Narita
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ryo Ishii
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
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de Sousa Arantes Ferreira G, Conde Watanabe AL, de Carvalho Trevizoli N, Felippe Jorge FM, Ferreira Figueira AV, de Fatima Couto C, Viana de Lima L, Liduario Raupp DR. Tacrolimus-Associated Psychotic Disorder: A Report of 2 Cases. Transplant Proc 2020; 52:1350-1353. [PMID: 32197865 DOI: 10.1016/j.transproceed.2020.01.076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/22/2020] [Indexed: 02/07/2023]
Abstract
Psychotic disorders are a group of psychiatric disorders characterized by the presence of delusions, hallucinations, bizarre behavior, and disorganized speech. There are several possible causes for the occurrence of psychotic disorders in patients who underwent solid organ transplant, including pre-existing mental illness, electrolyte disturbances, infections of the central nervous system, and adverse reaction to drugs. Calcineurin inhibitors are a class of immunosuppressive drugs, such as tacrolimus and cyclosporine, that are currently considered the mainstay in the immunosuppressive drug regimen of patients who underwent solid organ transplant. Neurotoxicity is one of the adverse reactions associated with the use of calcineurin inhibitors, ranging from upper limb tremors to psychotic disorders and seizures. We report the cases of 2 liver transplant recipients who developed severe psychotic disorder 1 month after the procedure. After an extensive investigation for other possible triggers of psychiatric disease, the use of tacrolimus was considered to be the most likely cause for the acute psychotic disorder. In less than 24 hours after suspension of that drug, all symptoms disappeared in both patients, making a causal relationship with tacrolimus even more likely. The patients were then given cyclosporine, another drug from the same class, allowing for adequate immunosuppression and preserved graft function, with no further psychiatric symptoms. This report confirms that a 24-hour trial of tacrolimus suspension can be safe and effective in the diagnosis of drug-related psychotic disorders in patients who underwent liver transplant. This article is compliant with the Helsinki Congress and the Istanbul Declaration.
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Schmidbauer ML, Wollenweber FA, Straube A, Kamm K. [Drug-induced reversible cerebral vasoconstriction syndrome : Ustekinumab as possible trigger?]. Schmerz 2020; 34:350-353. [PMID: 32435940 DOI: 10.1007/s00482-020-00479-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The reversible cerebral vasoconstriction syndrome (RCVS) is a common cause of thunderclap headache. Many trigger factors, such as the intake of vasoactive and less commonly immunosuppressive medication have previously been described. This article reports the first case of the occurrence of RCVS after the intake of ustekinumab in a female patient with a history of Crohn's disease.
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Affiliation(s)
- Moritz Luigi Schmidbauer
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - Frank Arne Wollenweber
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland.,Klinik für Neurologie, Helios Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Deutschland
| | - Andreas Straube
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland
| | - Katharina Kamm
- Klinik und Poliklinik für Neurologie, Klinikum der Universität München, Campus Großhadern, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, München, Deutschland.
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Maeda S, Saito S, Toda K, Miyagawa S, Yoshikawa Y, Hata H, Yoshioka D, Tsukamoto Y, Sakata Y, Sawa Y. A case of tacrolimus-induced reversible cerebral vasoconstriction syndrome after heart transplantation. Gen Thorac Cardiovasc Surg 2020; 68:1483-1486. [DOI: 10.1007/s11748-020-01309-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 01/29/2020] [Indexed: 11/24/2022]
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Gonzalez-Martinez A, Romero-Palacián D, Dotor García-Soto J, Sánchez P, Reig Roselló G, Zapata Wainberg G. Tocilizumab-Associated Reversible Cerebral Vasoconstriction: A Case Report. Headache 2019; 59:259-263. [PMID: 30653667 DOI: 10.1111/head.13466] [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] [Accepted: 11/09/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To report a case of reversible cerebral vasoconstriction syndrome (RCVS) possibly precipitated by tocilizumab. BACKGROUND Immunosuppressant drugs are a rare cause of reversible cerebral vasoconstriction, a syndrome characterized by segmental vasospasm. However, although it is considered a reversible process that resolves within 3 months, the cerebral vasoconstriction over time may lead to severe complications such as strokes. RESULTS We describe a 53-year-old woman who presented with a reversible vasoconstriction syndrome possibly associated with tocilizumab, an inhibitor of IL-6 receptor used in inflammatory diseases such as rheumatoid arthritis. The patient developed a cerebellar infarction as the major complication of the vasoconstriction syndrome. CONCLUSION Tocilizumab could be a trigger of RCVS. It is important to bear in mind the role of tocilizumab as a possible precipitating factor in order to remove it and reduce complications such as strokes. It is, to our knowledge, the first reversible vasoconstriction syndrome possibly precipitated by tocilizumab published to date.
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Affiliation(s)
- Alicia Gonzalez-Martinez
- Department of Neurology & Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - Daniel Romero-Palacián
- Department of Clinical Pharmacology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Julio Dotor García-Soto
- Department of Neurology & Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - Pedro Sánchez
- Department of Neurology & Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - Gemma Reig Roselló
- Department of Neurology & Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
| | - Gustavo Zapata Wainberg
- Department of Neurology & Instituto de Investigación Sanitaria La Princesa, Hospital Universitario de la Princesa, Madrid, Spain
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Gonsales D, Gracas FD, Santos R, Aguilar-Salinas P, Hanel RA. Reversible Cerebral Vasoconstriction Syndrome as an Unusual Complication of a Dural Arteriovenous Fistula treated with Onyx Embolization. World Neurosurg 2018; 115:341-345. [PMID: 29751188 DOI: 10.1016/j.wneu.2018.04.211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome (RCVS) is a rare entity with an unknown pathophysiology. RCVS has been reported to occur more frequently in women age 20-50 years. Several causative mechanisms have been postulated involving transient deregulation of cerebral arterial tone, small vessel endothelial dysfunction, biochemical factors, hormonal deregulation, oxidative stress, and genetic predisposition. All these mechanisms and triggers are related to sympathetic overactivation, which eventually produces vasoconstriction. RCVS is distinguished by acute severe recurrent thunderclap headaches with or without other neurologic symptoms. However, the diagnosis can be challenging, requiring a high level of suspicion by the clinician, and RCVS is often underdiagnosed. CASE DESCRIPTION We present an unusual case of an 18-year-old female who developed RCVS after embolization of a dural arteriovenous fistula with onyx embolic material. Cerebral angiography was performed and verapamil was administered intra-arterially, resulting in a slight decrease in vasoconstriction with clinical improvement. The patient was maintained on oral verapamil during hospitalization. At a 7-month follow-up, the patient was neurologically stable, and cerebral angiography demonstrated no signs of vasoconstriction. CONCLUSIONS Endovascular procedures are a rare trigger for the development of RCVS and may be misdiagnosed. Prompt recognition of symptoms and diagnosis with treatment are necessary to reduce the risk of stroke. The management approach should be based on the premise of discontinuing precipitating drugs and administering calcium channel blocking agents.
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Affiliation(s)
- Douglas Gonsales
- Baptist Neurological Institute, Lyerly Neurosurgery-Baptist Health, Jacksonville, Florida, USA
| | - Fabiano das Gracas
- Baptist Neurological Institute, Lyerly Neurosurgery-Baptist Health, Jacksonville, Florida, USA
| | - Roberta Santos
- Baptist Neurological Institute, Lyerly Neurosurgery-Baptist Health, Jacksonville, Florida, USA
| | - Pedro Aguilar-Salinas
- Baptist Neurological Institute, Lyerly Neurosurgery-Baptist Health, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Baptist Neurological Institute, Lyerly Neurosurgery-Baptist Health, Jacksonville, Florida, USA.
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