Progressive multifocal leukoencephalopathy after liver transplantation can have favorable or unfavorable outcome

Calcineurin inhibitors-related posterior reversible encephalopathy syndrome in liver transplant recipients: Three case reports and review of literature

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES), characterized by acute neurological deterioration and extensive white matter lesions on T2-fluid attenuated inversion recovery magnetic resonance imaging (MRI), is increasingly associated with calcineurin inhibitors (CNI)-related neurotoxicity. Prompt diagnosis is crucial, as early intervention, including the modification or discontinuation of CNI therapy, strict blood pressure management, corticosteroid treatment, and supportive care can significantly improve patient outcomes and prognosis. The growing clinical recognition of CNI-related PRES underscores the importance of identifying and managing this condition in patients presenting with acute neurological symptoms.

CASE SUMMARY

This report describes three cases of liver transplant recipients who developed PRES. The first case involves a 60-year-old woman who experienced seizures, aphasia, and hemiplegia on postoperative day (POD) 9, with MRI revealing ischemic foci followed by extensive white matter lesions. After replacing tacrolimus, her symptoms improved, and no significant MRI abnormalities were observed after three years of follow-up. The second case concerns a 54-year-old woman with autoimmune hepatitis who developed headaches, seizures, and extensive white matter demyelination on MRI on POD24. Following the switch to rapamycin and the initiation of corticosteroids, her symptoms resolved, and she was discharged on POD95. The third case details a 60-year-old woman with hepatocellular carcinoma who developed PRES, evidenced by brain MRI abnormalities on POD11. Transitioning to rapamycin and corticosteroid therapy led to her full recovery, and she was discharged on POD22. These cases highlight the critical importance of early diagnosis, CNI modification, and stringent management in improving outcomes for liver transplant recipients with CNI-related PRES.

CONCLUSION

Clinical manifestations, combined with characteristic MRI findings, are crucial in diagnosing PRES among organ transplant recipients. However, when standard treatments are ineffective or MRI results are atypical, alternative diagnoses should be taken into considered.

Progressive multifocal leukoencephalopathy presenting with acute sensorineural hearing loss in an intestinal transplant recipient

A 20-year-old male presented 3.5 years after intestinal transplantation with rapidly progressive sensorineural hearing loss. Initial brain imaging was consistent with inflammation and/or demyelination. Lumbar puncture was initially non-diagnostic and a broad infectious workup was unrevealing. Three months after presentation, a repeat LP detected JC virus for which tests had not earlier been conducted. He continued to deteriorate despite withdrawal of prior immunosuppression and addition of mirtazapine, maraviroc, and steroids. He died of progressive neurologic decompensation 5 months after his initial presentation. This case highlights progressive multifocal leukoencephalopathy (PML) as a rare complication after solid organ transplantation and acute sensorineural hearing loss as an unusual first presenting symptom of PML. JC virus should be considered in the differential diagnosis of acute sensorineural hearing loss in any immunocompromised patient.

Probable progressive multifocal leukoencephalopathy-immune reconstitution inflammatory syndrome with immunosuppressant dose reduction following lung transplantation: a case report and literature review

BACKGROUND

Progressive multifocal leukoencephalopathy (PML) is a rapidly developing demyelinating disease in the cerebral white matter and is often caused by JC polyomavirus (JCV). PML after lung transplantation is rare and has a poor prognosis, with no established therapies. Reducing the patient's immunosuppressant doses, thereby restoring immunity, could be used to treat PML. However, some patients develop immune reconstitution inflammatory syndrome (IRIS) with this treatment, an immune-induced inflammatory response to JCV that results in serious neuronal damage. We herein report a case of a 60-year-old female who suffered from PML 5 years after lung transplantation, had worsened brain lesions thought to be related to PML-IRIS at the time of immunosuppressant reduction, and missed treatment opportunities.

CASE PRESENTATION

A 60-year-old female developed PML 5 years after lung transplantation. Fluid-attenuated inversion recovery and diffusion-weighted brain magnetic resonance imaging (MRI) revealed multiple high-signal lesions, mainly in the cerebral white matter. Polymerase chain reaction found 0.32 million copies/mL of JCV in the cerebrospinal fluid. Thus, she was given a diagnosis of PML. Mycophenolate mofetil and tacrolimus dosages were reduced, and CD4-positive cell counts and the blood concentration of each immunosuppressant were monitored. Mefloquine was also orally administered at a daily dose of 275 mg for 3 days and was then administered at a dose of 275 mg per week. Although the patient's CD4-positive cell counts increased and her immune system recovered, her symptoms and brain MRI findings worsened. We suspected PML progression or a transition to PML-IRIS. Steroid pulse therapy to suppress the inflammatory lesions was not possible but was retrospectively indicated. The patient rapidly began to exhibit akinetic mutism and died 4 months after the onset of neurologic symptoms.

CONCLUSIONS

When neurologic symptoms and abnormal brain MRI findings are noted during immune recovery, it is often difficult to distinguish between progressed PML and PML-IRIS. However, the pathogenesis of brain lesions usually involves inflammation and immune-reactive mechanisms for JCV. Steroid pulse therapy, which can reduce inflammation, should thus be administered in organ transplantation cases with differential diagnoses including PML-IRIS.