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Verona P, Edwards J, Hubert K, Avorio F, Re VL, Di Stefano R, Carollo A, Johnson H, Provenzani A. Tacrolimus-Induced Neurotoxicity After Transplant: A Literature Review. Drug Saf 2024; 47:419-438. [PMID: 38353884 DOI: 10.1007/s40264-024-01398-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 04/17/2024]
Abstract
Tacrolimus, a calcineurin inhibitor, is an immunosuppressant used globally to prevent rejection after organ transplantation. Although it significantly improves outcomes for solid organ transplant patients, it is associated with various side effects such as nephrotoxicity and neurotoxicity. Tacrolimus-induced neurotoxicity is frequently encountered in clinical practice and can present with a variety of symptoms that may occur even at therapeutic levels. Although tacrolimus-induced neurotoxicity is well documented, there is limited literature available on pharmacologic management. Twenty-eight case reports of tacrolimus-induced neurotoxicity were identified and analyzed in addition to other literature including reviews, retrospective studies, and animal model studies. The severity of cases of tacrolimus-induced neurotoxicity reported ranged from mild symptoms that could be managed with symptomatic treatment to conditions such as posterior reversible encephalopathy syndrome and chronic inflammatory demyelinating polyradiculoneuropathy that may require more immediate intervention. This information was utilized in addition to clinical experience to compile potential management options for prevention and treatment of neurotoxic adverse events. This review is limited by the utilization of primarily retrospective studies and case reports. The available literature on the subject is largely narrative and there are no guidelines on treatment of tacrolimus-induced neurotoxicity at the time of this research. This comprehensive review may guide further studies to investigate the pathophysiology of tacrolimus-induced neurotoxicity and to define patient-specific strategies for mitigation or minimization of neurotoxicity. This is especially important given that management of tacrolimus-induced neurotoxicity can include changes to immunosuppression that can result in an increased risk of rejection.
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Affiliation(s)
- Paige Verona
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jocelyn Edwards
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kassidy Hubert
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Federica Avorio
- Neurology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Vincenzina Lo Re
- Neurology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy
| | - Roberta Di Stefano
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via E.Tricomi n. 5, 90127, Palermo, Italy
| | - Anna Carollo
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via E.Tricomi n. 5, 90127, Palermo, Italy
| | - Heather Johnson
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA, USA
| | - Alessio Provenzani
- Clinical Pharmacy Service, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Via E.Tricomi n. 5, 90127, Palermo, Italy.
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Ajmi H, Brahim J, Mabrouk S, Ben Abdallah A, Zouari N, Majdoub F, Nouir S, Hasni I, Ben Cheikh Y, Chemli J, Jemni H, Abroug S. Clinical and radiological findings of posterior reversible encephalopathy syndrome in children: About 16 children hospitalized in the pediatric department of a Tunisian tertiary care hospital. Eur J Paediatr Neurol 2023; 43:18-26. [PMID: 36871341 DOI: 10.1016/j.ejpn.2023.02.003] [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: 10/20/2021] [Revised: 11/24/2022] [Accepted: 02/12/2023] [Indexed: 02/21/2023]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiological entity most frequently described in young- or middle-aged adults with a rare occurrence among children. AIM To determine the clinical, radiological features and outcome of PRES in children admitted to a Tunisian tertiary care pediatric department. METHODS we retrospectively reviewed records of all children under 18 years old diagnosed with PRES and admitted to the PICU of the Pediatric department of Sahloul University Hospital from January 2000 to August 2021. RESULTS Sixteen patients were enrolled in this study. The mean age of the study population at PRES onset was 10 years (range: 4-14 years) and the male female ratio was 3. The most frequent neurological signs were seizures (n = 16 cases), headache (n = 8 cases), and impaired level of consciousness (7 cases). Visual disturbances were found in one patient. Arterial hypertension was the most underlying cause (16 cases). Brain MRI showed vasogenic edema, mostly localized in the parietal (13 cases) and occipital (11 cases) lobes. Moreover, cytotoxic edema (2 cases), pathologic contrast enhancement (1 case), and hemorrhage (3 cases) were isolated on MRI. The outcome after specific management was favorable after the first onset in 13 cases and death occurred in 3 patients. Relapses were observed in 4 patients. CONCLUSION Clinical features presented by children with PRES are variable and non-specific. MRI typically shows reversible posterior cerebral edema. However, in some cases, atypical neuro-imaging findings, such as cytotoxic edema infarction, hemorrhage and contrast enhancement can be observed.
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Affiliation(s)
- Houda Ajmi
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia.
| | - Jawher Brahim
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Sameh Mabrouk
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Amel Ben Abdallah
- Department of Radiology, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Noura Zouari
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Fadoua Majdoub
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Salsabil Nouir
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Ibtissem Hasni
- Department of Radiology, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Yasser Ben Cheikh
- Department of Radiology, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Jalel Chemli
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Hela Jemni
- Department of Radiology, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
| | - Saoussan Abroug
- Department of Pediatrics, Sahloul Teaching Hospital, 4054, Sousse, Tunisia
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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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Posterior Reversible Encephalopathy Syndrome Associated with Tacrolimus in Cardiac Transplantation. Case Rep Cardiol 2021; 2021:9998205. [PMID: 34258073 PMCID: PMC8253642 DOI: 10.1155/2021/9998205] [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] [Received: 03/12/2021] [Accepted: 06/10/2021] [Indexed: 11/04/2022] Open
Abstract
Background Neurological complications occur between 50 and 70% of patients with heart transplantation, including cerebrovascular events, infections, seizures, encephalopathy, and neurotoxicity due to pharmacological immunosuppression. Mortality associated with cerebrovascular complications is 7.5% in the first 30 days and up to 5.3% after the first month and up to the first year after transplantation. Case Reports. Three heart-transplanted patients (2 men and 1 woman) treated with tacrolimus were identified. They presented with posterior reversible encephalopathy syndrome on days 5, 6, and 58 posttransplantation, respectively. In these reported cases, no sequelae were observed at 6 months follow-up. Conclusions Posterior reversible encephalopathy syndrome as a neurological complication in patients with HT occurred early after the procedure. Early diagnosis and treatment might reduce the risk of serious complications and mortality.
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Vernaza A, Pinilla-Monsalve G, Cañas F, Carrillo D, David López J, Flórez N, Gomez-Mesa JE. Malaria and encephalopathy in a heart transplant recipient: A case report in the context of multiorgan donation. Transpl Infect Dis 2021; 23:e13565. [PMID: 33432737 DOI: 10.1111/tid.13565] [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] [Received: 08/14/2020] [Revised: 12/10/2020] [Accepted: 12/30/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Malaria is an endemic infection in tropical circles. It can be transmitted from mosquitoes bite, but exceptional cases have been attributed to multiorgan transplantation. CASE REPORT This is a 34-year-old woman who received a heart transplant for final-stage dilated cardiomyopathy. Over the hospitalization, she developed fever, cephalalgia, and tonic-clonic seizures with MRI findings compatible with posterior reversible encephalopathy. A thick blood smear revealed hemoparasitic forms of Plasmodium vivax. Afterward, malaria was also diagnosed in recipients of one kidney and liver of the same organ donor. First-line treatment with artesunate was prescribed for 3 days and chloroquine with primaquine thereafter for 14 days. The patient was discharged and returned to the emergency department 5 days later, complaining of gastrointestinal symptoms and developed multiorgan failure that led to death. CONCLUSION We report a case of malaria transmission through heart transplantation. Despite adequate and supervised treatment, it can be related to a fatal outcome. Malaria screening in organ donors should be considered in regions where endemicity can lead to rare cases of transmission by transplantation.
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Affiliation(s)
- Armando Vernaza
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Gabriel Pinilla-Monsalve
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Neurology, Fundación Valle del Lili, Cali, Colombia
| | - Felipe Cañas
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Diana Carrillo
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Juan David López
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Noel Flórez
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
| | - Juan Esteban Gomez-Mesa
- Faculty of Health Sciences, Icesi University, Cali, Colombia.,Department of Cardiology, Fundación Valle del Lili, Cali, Colombia
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Gilbert BW, Gabriel A, Velazquez L. A Case of Antibiotic-Induced Posterior Reversible Encephalopathy Syndrome. Hosp Pharm 2019; 55:338-341. [PMID: 32999504 DOI: 10.1177/0018578719844706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To report a case of posterior reversible encephalopathy syndrome (PRES) in a 75 year-old patient who was taking concomitant ciprofloxacin and metronidazole. Method: Case report Results: A patient had been prescribed ciprofloxacin and metronidazole during a recent hospitalization and continued this regimen outpatient. Two weeks after discharge and 3 weeks after initiation of her regimen, she was brought to the emergency department after developing acute weakness and lightheadedness. After admission, the patient declined more rapidly and began seizing with subsequent intubation. Initial computed tomographic (CT) imaging showed no acute neurological abnormalities, and a sepsis workup was initiated. After negative CT, a magnetic resonance imaging scan was performed that showed a T2 flair and hyperdensity consistent with PRES. The final diagnosis was considered to be PRES secondary to ciprofloxacin/metronidazole utilization. Conclusion: Antibiotic induced PRES is a condition that needs to be explored more thoroughly.
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