Blindness after liver transplant

Etiologies, Cerebral Vasomotion, and Endothelial Dysfunction in the Pathophysiology of Posterior Reversible Encephalopathy Syndrome in Pediatric Patients

The 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.

Posterior reversible encephalopathy syndrome in pediatric patients: pathophysiology, diagnosis, and management

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.

[Posterior reversible encephalopathy related to tacrolimus in a liver transplanted HIV patient]

Tacrolimus-related posterior reversible leukoencephalopathy (PRLE) is a rare complication which should be recognized by clinicians who regularly use immunosuppressive therapy. We report the case of an HIV-positive, hepatitis C-positive liver transplant patient who presented with this complication. Immunosuppression with tacrolimus was started after postsurgery. On the 20th day, the patient suffered two tonic-clonic convulsive attacks against a background of hypertension. Cerebral magnetic resonance imaging and lumbar puncture led to diagnosis of tacrolimus-related PRLE after eliminating other possible diagnoses. Therapeutic management consisted of withdrawing tacrolimus and initiating treatment with antiepileptogenic and antihypertensive drugs, supplemented with magnesium sulphate. The symptoms regressed in the days following withdrawal of tacrolimus and the majority of lesions on magnetic resonance imaging disappeared within two weeks. The aim of which should be to identify patients at risk of developing this complication. This would enable targeted prevention involving magnesium supplementation, strict control of blood pressure and serial monitoring of tacrolimus blood concentrations.

Reversible posterior leukoencephalopathy syndrome: report of 2 simultaneous cases in children

Reversible posterior leukoencephalopathy syndrome (RPLS) is a rare complication of cancer chemotherapy. We have recently observed two cases occurred simultaneously in children receiving different chemotherapy regimens, for hepatoblastoma and acute lymphoblastic leukaemia, respectively. Both children presented with altered mental status, severe visual disturbances, headache, seizures, backpain and hypertension. Magnetic resonance imaging showed cortical and subcortical lesions especially in the occipital and parietal regions, strongly consistent with RPLS. Both patients completely recovered from their neuropsychologic deficits in about ten days only with anticonvulsant and antihypertensive therapy, and chemotherapy regimen was promptly restarted according to the planned protocol, without any neuropsychological sequela. A mild left midriasis was the only neurologic defect that persisted in the patient with acute lymphoblastic leukemia.

Progressive bilateral sensorineural hearing loss probably induced by chronic cyclosporin A treatment after renal transplantation for focal glomerulosclerosis

OBJECTIVE

The immunosuppressive agent cyclosporin A (CsA) has contributed to the success of organ and bone marrow transplantation. CsA-related neurotoxicity is a well-known occurrence. Sensorineural hearing loss (SNHL) due to initiation of CsA treatment is an extremely rare finding.

MATERIAL AND METHODS

A 32-year-old man who had undergone technically uneventful cadaveric renal transplantation for focal glomerulosclerosis when 25 years old was evaluated as the result of a 10-month history of bilateral hearing loss. The patient had been taking only CsA (150 mg twice daily) and methylprednisolone.

RESULTS

Progressive bilateral SNHL was confirmed by an audiological examination. Eight months after dose reduction of CsA, pure-tone audiometry excluded progression of hearing loss.

CONCLUSIONS

To the best of our knowledge, only rare cases of CsA-related hearing loss have been reported, and none after long-term CsA treatment. Audiological findings confirmed the cochlear origin of SNHL in our patient. The action of CsA on the blood-inner ear barrier has recently been demonstrated but the mechanism of cochlear damage is still unknown. A prospective study to determine the incidence of CsA-induced hearing loss has been instituted in our department.

Stage IV hepatic encephalopathy associated with acute blindness after liver transplantation

A 5-yr-old boy who diagnosed acute liver failure and Stage IV hepatic encephalopathy underwent living related liver transplantation and awakened with persistent hand motions visual loss. Serum Tacrolimus, electrolytes, magnesium levels were normal as well as blood pressure. His neurologic and opthamologic examinations were otherwise normal. Visual evoked potential (VEP) was prolonged and brain magnetic resonance immaging (MRI) revealed bilateral parietooccipital white matter signal abnormalities with gliosis. During follow up his visual loss resolved spontoneously as well as the VEP and MRI abnormalities. In this case we aimed to point out hepatic encephalopathy might be a cause of postoperative visual loss and serial VEP analysis is an important diagnostic tool for monitoring visual function of liver graft recipients in the post-operative period.