1
|
Dilibe A, Subramanian L, Poyser TA, Oriaifo O, Brady R, Srikanth S, Adabale O, Bolaji OA, Ali H. Tacrolimus-induced posterior reversible encephalopathy syndrome following liver transplantation. World J Transplant 2024; 14:91146. [PMID: 38947962 PMCID: PMC11212591 DOI: 10.5500/wjt.v14.i2.91146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 04/13/2024] [Accepted: 04/25/2024] [Indexed: 06/13/2024] Open
Abstract
In this editorial, we talk about a compelling case focusing on posterior reversible encephalopathy syndrome (PRES) as a complication in patients undergoing liver transplantation and treated with Tacrolimus. Tacrolimus (FK 506), derived from Streptomyces tsukubaensis, is a potent immunosuppressive macrolide. It inhibits T-cell transcription by binding to FK-binding protein, and is able to amplify glucocorticoid and progesterone effects. Tacrolimus effectively prevents allograft rejection in transplant patients but has adverse effects such as Tacrolimus-related PRES. PRES presents with various neurological symptoms alongside elevated blood pressure, and is primarily characterized by vasogenic edema on neuroimaging. While computed tomography detects initial lesions, magnetic resonance imaging, especially the Fluid-Attenuated Inversion Recovery sequence, is superior for diagnosing cortical and subcortical edema. Our discussion centers on the incidence of PRES in solid organ transplant recipients, which ranges between 0.5 to 5 +ACU-, with varying presentations, from seizures to visual disturbances. The case of a 66-year-old male status post liver transplantation highlights the diagnostic and management challenges associated with Tacrolimus-related PRES. Radiographically evident in the parietal and occipital lobes, PRES underlines the need for heightened vigilance among healthcare providers. This editorial emphasizes the importance of early recognition, accurate diagnosis, and effective management of PRES to optimize outcomes in liver transplant patients. The case further explores the balance between the efficacy of immunosuppression with Tacrolimus and its potential neurological risks, underlining the necessity for careful monitoring and intervention strategies in this patient population.
Collapse
Affiliation(s)
- Arthur Dilibe
- Department of Medicine, ECU Health Medical Center, Greenville, NC 27834, United States
| | - Lakshmi Subramanian
- Department of Medicine, ECU Health Medical Center, Greenville, NC 27834, United States
| | - Tracy-Ann Poyser
- Department of Medicine, Unity Health-White County Medical Center, Searcy, AR 72143, United States
| | - Osejie Oriaifo
- Department of Medicine, ECU Health Medical Center, Greenville, NC 27834, United States
| | - Ryan Brady
- Department of Physical Medicine and Rehab, ECU Health Medical Center, Greenville, NC 27834, United States
| | - Sashwath Srikanth
- Department of Medicine, ECU Health Medical Center, Greenville, NC 27834, United States
| | - Olanrewaju Adabale
- Department of Medicine, ECU Health Medical Center, Greenville, NC 27834, United States
| | - Olayiwola Akeem Bolaji
- Department of Medicine, University of Maryland Capital Region Health, Largo, MD 20774, United States
| | - Hassam Ali
- Division of Gastroenterology and Hepatology, East Carolina University/Brody School of Medicine, Greenville, NC 27858, United States
| |
Collapse
|
2
|
Markan A, Ayyadurai N, Singh R. Tacrolimus Induced Thrombotic Microangiopathy (TMA) Presenting as Acute Macular Neuroretinopathy. Ocul Immunol Inflamm 2023; 31:231-232. [PMID: 34855579 DOI: 10.1080/09273948.2021.1998549] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This report highlights the association of tacrolimus use with acute macular neuroretinopathy (AMN). A 27-year-old woman, a known case of diffuse proliferative membranous glomerulonephritis, developed abnormal body movements, loss of consciousness, and blurring of vision in the left eye, after 3 months of starting tacrolimus. Blood investigations revealed anemia, thrombocytopenia, raised urea and creatinine levels, and raised LDH levels. A diagnosis of tacrolimus induced hemolytic uremic syndrome (HUS) with posterior reversible encephalopathy syndrome (PRES) was made. Ocular examination revealed a reddish-brown petaloid retinal lesion, which was better appreciated on red-free imaging as dark grey area pointing towards the fovea. OCT-A and SD-OCT revealed flow voids in deep retinal plexus, and disruption of ellipsoid and interdigitation zone, respectively, findings consistent with AMN. To the best of our knowledge, it is the first report of association of tacrolimus with AMN.
Collapse
Affiliation(s)
- Ashish Markan
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nikitha Ayyadurai
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh
- Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
3
|
[More than "just" a provoked seizure in association with a known history of epilepsy]. Med Klin Intensivmed Notfmed 2022; 117:571-574. [PMID: 35704057 DOI: 10.1007/s00063-022-00936-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/16/2022] [Accepted: 05/24/2022] [Indexed: 01/05/2023]
|
4
|
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.
Collapse
|
5
|
Wang Z, Zhao M, Gao S. Epileptic Seizures After Allogeneic Hematopoietic Stem Cell Transplantation. Front Neurol 2021; 12:675756. [PMID: 34335446 PMCID: PMC8322618 DOI: 10.3389/fneur.2021.675756] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
Technique in allogeneic hematopoietic stem cell transplantation has greatly advanced over the past decades, which has led to an increase in the number of patients receiving transplantation, but the complex procedure places these transplant recipients at high risk of a large spectrum of complications including neurologic involvement. As a common manifestation of neurological disorders, epileptic seizures after transplantation have been of great concern to clinicians because it seriously affects the survival rate and living quality of those recipients. The aim of this review is to elucidate the incidence of seizures after allogeneic hematopoietic stem cell transplantation, and to further summarize in detail its etiologies, possible mechanisms, clinical manifestations, therapeutic schedule, and prognosis, hoping to improve doctors' understandings of concurrent seizures following transplantation, so they can prevent, process, and eventually improve the survival and outlook for patients in a timely manner and correctly.
Collapse
Affiliation(s)
- Zhuo Wang
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Munan Zhao
- Department of Oncology, The First Hospital of Jilin University, Changchun, China
| | - Sujun Gao
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| |
Collapse
|
6
|
Hubbard ME, Phillips AA, Charbonneau R, Squair JW, Parr AM, Krassioukov A. PRES secondary to autonomic dysreflexia: A case series and review of the literature. J Spinal Cord Med 2021; 44:606-612. [PMID: 31140946 PMCID: PMC8288129 DOI: 10.1080/10790268.2019.1616146] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Context: Autonomic dysreflexia (AD) is a complex syndrome seen in patients with spinal cord injuries (SCI) and can be life-threatening with a significant negative impact on the health of the individual. Posterior reversible encephalopathy syndrome (PRES) is thought to be caused, in part, by rapid elevations in blood pressure; leading to posterior cerebral circulatory edema. This can result in seizures, blindness and can progress to fatal intracranial hemorrhages.Findings: Here we present two cases of patients with SCI who developed PRES from AD. Each patient was correctly diagnosed, leading to appropriate treatment of the factors leading to their AD and subsequent resolution of their PRES symptoms.Conclusions/Clinical Relevance: In SCI patients who present with new seizures, visual deficits, or other neurologic signs, PRES should be considered as a part of the differential diagnosis as a good outcome relies on rapid recognition and treatment of AD.
Collapse
Affiliation(s)
- Molly E. Hubbard
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA,Correspondence to: Molly E. Hubbard, Department of Neurosurgery, University of Minnesota, MMC 96 Room D-429, Mayo Building, 420 Delaware St SE, Minneapolis, MN55455, USA; Ph: 612-624-6666.
| | - Aaron A. Phillips
- Departments of Physiology and Pharmacology and Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Rebecca Charbonneau
- Department of Physical Medicine and Rehabilitation, University of Alberta, Calgary, AB, Canada
| | - Jordan W. Squair
- Department of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada
| | - Ann M. Parr
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Andrei Krassioukov
- Department of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
7
|
Butryn M, Mewes S, Feist E, Beuing O, Müller C, Neumann J. Tocilizumab-associated posterior reversible encephalopathy syndrome in giant-cell arteritis - case report. BMC Neurol 2021; 21:228. [PMID: 34157987 PMCID: PMC8218423 DOI: 10.1186/s12883-021-02231-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 05/11/2021] [Indexed: 11/24/2022] Open
Abstract
Backround We describe one of the first cases of a Posterior reversible encephalopathy syndrome (PRES) under tocilizumab as treatment of Giant cell arteritis (GCA). Case presentation A 65-year-old female with known GCA and treatment with Tocilizumab (TCZ) developed a convulsive epileptic seizure for the first time. MRI was suggestive of PRES and an associated left sided occipital hemorrhage. Extensive high blood pressure values were not detected. The patient recovered within a week and no further seizures occurred under anticonvulsive medication. Conclusion PRES during the treatment with Tocilizumab hasn’t been described in GCA so far. There are single reports of an association between TCZ and PRES in other entities. Thus, a link between interleukin-6 and the integrity of the vasculature could be considered. The clinical consequence should be a stringent blood pressure monitoring in the ambulant setting of patients receiving TCZ.
Collapse
Affiliation(s)
- Michaela Butryn
- Institute of Cognitive Neurology and Dementia Research, Otto von Guericke University Magdeburg, Magdeburg, Germany.,German Centre for Neurodegenerative Diseases, Magdeburg, Germany.,Department of Neurology, Otto von Guericke University Magdeburg, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Sabine Mewes
- Department of Rheumatology,
- Helios clinic, Gommern, Germany
| | - Eugen Feist
- Department of Rheumatology,
- Helios clinic, Gommern, Germany
| | - Oliver Beuing
- Department of Radiology, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Christian Müller
- Department of Gastroenterology, Hepatology und Infectiology, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Jens Neumann
- Department of Neurology, Otto von Guericke University Magdeburg, Leipziger Straße 44, 39120, Magdeburg, Germany.
| |
Collapse
|
8
|
Ramkissoon R, Yung-Lun Chin J, Jophlin L. Acute Neurological Symptoms After a Liver Transplant. Gastroenterology 2021; 160:2264-2266. [PMID: 33221403 DOI: 10.1053/j.gastro.2020.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/09/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Resham Ramkissoon
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Jerry Yung-Lun Chin
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Loretta Jophlin
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
9
|
Mappin-Kasirer B, Hoffman L, Sandal S. New-onset Psychosis in an Immunosuppressed Patient With Kidney Transplantation: An Educational Case Report. Can J Kidney Health Dis 2020; 7:2054358120947210. [PMID: 32821416 PMCID: PMC7412902 DOI: 10.1177/2054358120947210] [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] [Received: 03/26/2020] [Accepted: 06/12/2020] [Indexed: 11/17/2022] Open
Abstract
Rationale New-onset psychosis in an immunosuppressed patient post-kidney transplantation (KT) is a diagnostic challenge. A broad differential diagnosis merits consideration; however, an approach to this differential diagnosis remains to be outlined in the literature. Also, when and how to modify the maintenance immunosuppressive regimen remains a significant area of controversy. Presenting concerns A 23-year-old male, known for X-linked Alport syndrome for which he had undergone KT 1 year prior, presented with a 1-week history of disorganized speech, bizarre behavior, religious delusions, and visual hallucinations. Diagnoses After ruling out infectious, metabolic, autoimmune, and structural causes, immunosuppressant medications were changed from tacrolimus to cyclosporine. The patient did not improve after this change, and a second opinion consultation with a transplant psychiatrist led to a diagnosis of primary first-episode psychosis, later refined to bipolar disorder type I. Interventions The patient was started on risperidone, which led to a significant improvement in his symptoms. Outcomes Twelve months after discharge, his mood and behavior had returned to baseline on aripiprazole, bupropion, and citalopram. However, he developed acute allograft rejection, prompting a change from cyclosporine back to tacrolimus, with stability of his mental state and graft function. Teaching points This report offers learners an extensive and organized differential diagnosis to the work up of psychosis post kidney transplantation. A complete history, with input from collateral sources, and a systematic approach to the differential diagnosis, are crucial and should not be overshadowed by the risk of immunosuppressant-related neurotoxicity. We underscore the importance of multi-disciplinary management and comprehensive psychosocial assessment and re-assessment to refine the diagnosis. We also report the successful re-introduction of tacrolimus once the diagnosis of a primary psychiatric disorder is confirmed. Finally, we offer a simplified approach that can aid in distinguishing between a primary psychiatric diagnosis versus tacrolimus-associated psychosis.
Collapse
Affiliation(s)
| | - Lawrence Hoffman
- Department of Psychiatry, McGill University Health Centre, Montreal, QC, Canada
| | - Shaifali Sandal
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Nephrology Division, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada
| |
Collapse
|
10
|
Abstract
PURPOSE OF REVIEW The diagnosis of visual loss from toxic-metabolic and hereditary optic neuropathies may be delayed in some cases because of a failure to elicit important information in the clinical history or to recognize typical examination findings. An understanding of the features specific to each type of toxic-metabolic and hereditary optic neuropathy, and of the underlying mechanism of insult to the optic nerve, could lead to earlier recognition, diagnosis, and treatment (when available). RECENT FINDINGS Understanding of the role of mitochondria in toxic-metabolic and hereditary optic neuropathies is growing, particularly regarding the mechanism of insult of certain agents (medications and toxins) and of vitamin B12 deficiency. New developments in the quest for treatment for hereditary optic neuropathy, specifically Leber hereditary optic neuropathy, are being seen. SUMMARY Toxic-metabolic and hereditary optic neuropathies present in a similar fashion, with painless, progressive, bilateral visual loss with dyschromatopsia and cecocentral visual field defects. The associated retinal ganglion cell and axonal loss is typically due to mitochondrial dysfunction caused by an exogenous agent (toxic), by insufficient or deficient substrate (metabolic or nutritional), or by abnormal proteins or mitochondrial structure determined by a genetic mutation (hereditary).
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Li XY, Huang K, Zhou DH, Li Y, Xu HG, Weng WJ, Xu LH, Fang JP. Severe hypertension is an independent risk factor for posterior reversible encephalopathy syndrome post-hematopoietic cell transplantation in children with thalassemia major. Clin Transplant 2018; 33:e13459. [PMID: 30506735 DOI: 10.1111/ctr.13459] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/28/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is an increasingly recognized serious complication of cyclosporine A (CSA) and tacrolimus (TAC) use in hematopoietic cell transplantation (HCT) recipients. PROCEDURE A retrospective study was carried out, including 84 cases of HCT for TM from January 2012 to January 2017. Eleven cases were diagnosed with PRES. RESULTS The cumulative incidence of PRES was 13.4% (95% confidence interval (CI) 9.7%-17.2%). The median onset time of the symptoms was 63 [20, 143] days after transplantation. Lumber puncture found that CSF was normal. Univariate analysis showed that patients who received methylprednisolone (MP) (OR = 10.629 95% CI, 1.360-83.071, P = 0.024), female patients (OR = 4.275, 95% CI, 1.154-15.843, P = 0.032), patients who had severe hypertension (OR = 5.162, 95% CI, 1.042 to 25.559, P = 0.029) had significantly higher risks of PRES. Multivariate analysis showed that severe hypertension (hazard ratio [HR], 12.793; 95% CI, 1.477 to 110.813; P = 0.021), and Pesaro class 3 (HR, 3.367; 95% CI, 1.210 to 9.368; P = 0.020) were associated with PRES. CONCLUSIONS The severe hypertension is an independent risk factor for PRES post-HCT in children with thalassemia major. Patients of Pesaro class 3 may benefit from optimum control of blood pressure post-HCT for prophylaxis of PRES.
Collapse
Affiliation(s)
- Xin-Yu Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center (Pediatrics), Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ke Huang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center (Pediatrics), Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Dun-Hua Zhou
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center (Pediatrics), Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yang Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center (Pediatrics), Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hong-Gui Xu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center (Pediatrics), Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wen-Jun Weng
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center (Pediatrics), Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Lu-Hong Xu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center (Pediatrics), Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jian-Pei Fang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Medical Research Center (Pediatrics), Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| |
Collapse
|
13
|
Goklemez S, Curtis LM, Hawwa A, Ling A, Avila D, Heller T, Pavletic SZ. Achalasia in a Patient Undergoing Hematologic Stem Cell Transplant After Exposure to Tacrolimus. Mayo Clin Proc Innov Qual Outcomes 2018; 1:198-201. [PMID: 30225417 PMCID: PMC6134909 DOI: 10.1016/j.mayocpiqo.2017.06.004] [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] [Indexed: 11/24/2022] Open
Abstract
Calcineurin inhibitors (CNIs) are effective agents used for prevention of graft-vs-host disease after allogeneic hematopoietic stem cell transplant or for organ rejection in solid-organ transplant. However, CNIs have a wide range of adverse effects that may necessitate changing to another CNI or immunosuppressive agent. We report a case of acute myeloid leukemia in which achalasia developed after exposure to tacrolimus, as revealed by esophagram results. The patient's symptoms and signs were ameliorated after a change to cyclosporine. This case is the first in the literature to reveal achalasia associated with tacrolimus. Achalasia should be part of a differential diagnosis of upper gastrointestinal symptoms in patients undergoing transplant, and changing to another CNI may be a useful therapeutic intervention.
Collapse
Affiliation(s)
- Sencer Goklemez
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lauren M Curtis
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Alao Hawwa
- Translational Hepatology Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Alexander Ling
- Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD
| | - Daniele Avila
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Theo Heller
- Translational Hepatology Unit, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Steven Z Pavletic
- Experimental Transplantation and Immunology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD
| |
Collapse
|
14
|
Chandragiri S, Surendra M, Raju S, Sridhar N, Ramesh B, Raju N. Clinical Profile and Outcome of Posterior Reversible Encephalopathy Syndrome in Hemodialysis Patients. Indian J Nephrol 2018; 28:283-286. [PMID: 30158746 PMCID: PMC6094835 DOI: 10.4103/ijn.ijn_237_17] [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] [Indexed: 12/05/2022] Open
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiologic entity characterized by headache, altered level of consciousness, seizures, visual disturbances, and reversible vasogenic subcortical edema. Hypertension and renal failure are well known principal risk factors for the development of PRES. However, risk factors and outcome of PRES has not been studied in patients on maintenance hemodialysis (MHD). The objective of this study is to characterize the factors predisposing to the development of PRES in patients on MHD. We performed a retrospective analysis in patients of MHD who were diagnosed with PRES between August 1, 2013, and July 31, 2015. Those with a history of cerebrovascular accidents/stroke, and epilepsy were excluded. We analyzed the clinical details, course, and laboratory data. One year follow-up data were noted in recurrence of PRES and mortality. A total of 18 patients were included for the final analysis. Of these, 13 (72%) patients were males. Majority of these patients were young and mean age was 21.1 years (6–50 years). Most of the PRES episodes developed shortly after initiation of MHD with mean duration of 2 months after initiation of MHD (1 month–3 years). All 18 patients had resistant hypertension. Eight (45%) patients had infection at the time of PRES episodes. Four patients had catheter-related bloodstream infection, 1 had pneumonia and 3 patients were recently diagnosed with pulmonary tuberculosis. Four (22%) patients developed recurrence of PRES and all these episodes developed within 2 months of index event. Seven (39%) patients underwent renal transplantation, and all received triple immune suppression and had uncontrolled hypertension in the perioperative period. However, none of these patients developed PRES after transplantation. All these patients had been maintaining stable graft function in the follow-up. All episodes of PRES were of generalized tonic–clonic seizure type and 6 of them presented as status epilepticus. None of them had any neurological sequel and no mortality at the end of 1 year. PRES is not uncommon in patients on MHD. Uncontrolled hypertension and infection are common predisposing factors. Renal transplantation is safe and not adversely affected by prior episodes of PRES in MHD.
Collapse
Affiliation(s)
- S Chandragiri
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - M Surendra
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - S Raju
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - N Sridhar
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - B Ramesh
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - N Raju
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| |
Collapse
|
15
|
Kontzialis M, Huisman TAGM. Toxic-Metabolic Neurologic Disorders in Children: A Neuroimaging Review. J Neuroimaging 2018; 28:587-595. [PMID: 30066477 DOI: 10.1111/jon.12551] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 12/19/2022] Open
Abstract
There are multiple causes of neurotoxicity in children including medications, extrinsic toxins and insults, illicit drugs, built up of toxic metabolites due to genetic or acquired disorders, and metabolic abnormalities. The review is centered on causes of neurotoxicity affecting the pediatric brain and producing typical and easily recognized imaging manifestations. Early identification of common and less common imaging findings may point toward the correct direction, and may facilitate early diagnosis and institution of appropriate treatment to reverse or at least limit the injury to the developing brain. Two common imaging patterns of neurotoxicity in children are the posterior reversible encephalopathy syndrome and acute toxic leukoencephalopathy that are usually related to chemotherapy and immunosuppression for common pediatric malignancies. Another well-described imaging pattern of injury in children involves reversible splenial lesions with or without associated white matter abnormalities. Multiple additional extrinsic causes of neurotoxicity are presented including radiation and chemoradiation, various medications and treatment regimens, poisoning, illicit drug use or accidental exposure, and the respective characteristic neuroimaging findings are highlighted. Intrinsic neurotoxicity may occur in the setting of inborn errors of metabolism or acquired progressive organ failure leading to build up of toxic metabolites. Additional intrinsic causes of neurotoxicity include metabolic derangements and characteristic imaging findings in all instances are reviewed. The goal of the article is to enhance familiarity of neurologists and neuroradiologists with the imaging appearance of common and less common toxic insults to the pediatric brain.
Collapse
Affiliation(s)
- Marinos Kontzialis
- Section of Neuroradiology, Department of Radiology, Rush University Medical Center, Chicago, IL
| | - Thierry A G M Huisman
- Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
16
|
Davi CB, Moraes BPD, Lichtenfels BF, Castro Filho JBSD, Portal MM, Montenegro RM, Manfro RC. Posterior reversible leukoencephalopathy syndrome (PRES) after kidney transplantation: a case report. ACTA ACUST UNITED AC 2018; 40:91-94. [PMID: 29796585 PMCID: PMC6533973 DOI: 10.1590/1678-4685-jbn-3825] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/06/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Posterior reversible leukoencephalopathy syndrome (PRES) was first described by Hinchey in 1996. The syndrome is characterized by altered level of consciousness, headache, visual changes, and seizures associated with a vasogenic edema of the white matter that occurs predominantly in the occipital and parietal lobes. Imaging tests such as computed tomography (CT) and especially magnetic resonance imaging (MRI) support the diagnosis. CASE REPORT We report a case of a 48-year-old female patient who underwent a deceased donor kidney transplant and received tacrolimus as a part of the immunosuppressive regimen. Five weeks after transplantation she was admitted to the emergency due to sudden onset of confusion, disorientation, visual disturbances, and major headache. PRES was suspected and the diagnosis confirmed by brain MRI. Tacrolimus was withdrawn and rapid improvement of the neurological signs occurred leading to the conclusion that this drug triggered the syndrome. CONCLUSION PRES is an unusual complication after organ transplantation and should be considered in the appropriate clinical setting. Physicians must be aware of this condition in order to provide early detection and appropriate treatment since delay in removing the cause may lead to permanent sequelae.
Collapse
Affiliation(s)
- Carla Beatriz Davi
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Bruna Pinheiro de Moraes
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Bruno Fontes Lichtenfels
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | | | - Marcelle Maria Portal
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Rosangela Munhoz Montenegro
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | - Roberto Ceratti Manfro
- Universidade Federal do Rio Grande do Sul, Faculdade de Medicina, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| |
Collapse
|
17
|
Ganesh K, Nair RR, Kurian G, Mathew A, Sreedharan S, Paul Z. Posterior Reversible Encephalopathy Syndrome in Kidney Disease. Kidney Int Rep 2017; 3:502-507. [PMID: 29725657 PMCID: PMC5932131 DOI: 10.1016/j.ekir.2017.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Kartik Ganesh
- Department of Nephrology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Rajesh R Nair
- Department of Nephrology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - George Kurian
- Department of Nephrology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Anil Mathew
- Department of Nephrology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Sandeep Sreedharan
- Department of Nephrology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Zachariah Paul
- Department of Nephrology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| |
Collapse
|
18
|
Brown CH, Feng AJ, Cruz E. Ocular Dysfunctions Presenting in Tacrolimus-Induced Posterior Reversible Encephalopathy Syndrome: A Case Presentation. PM R 2017; 10:105-111. [PMID: 28911995 DOI: 10.1016/j.pmrj.2017.07.079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 07/12/2017] [Accepted: 07/22/2017] [Indexed: 11/16/2022]
Abstract
The constellation of ocular symptoms known as Balint syndrome is a rare disorder seen in bilateral parieto-occipital lesions and is most frequently due to arterial occlusive disease or acute hypertension. Here we present the case of a patient with tacrolimus-induced posterior reversible encephalopathy syndrome (PRES) who presented with optic ataxia, simultanagnosia, and ocular apraxia. These ocular findings, consistent with Balint syndrome, are rarely the initial presentation of PRES. This case highlights the importance of early recognition of this unusual phenomenon, as well as the importance of an individualized rehabilitation plan to maximize functional independence in these patients. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- Cora H Brown
- Department of Physical Medicine and Rehabilation, Temple University Hospital, Rock Pavilion, Lower Level, 3401 North Broad St, Philadelphia, PA 19140.,Department of Physical Medicine and Rehabilation, Temple University Hospital, Philadelphia, PA
| | - Alexander J Feng
- Department of Physical Medicine and Rehabilation, Temple University Hospital, Rock Pavilion, Lower Level, 3401 North Broad St, Philadelphia, PA 19140.,Department of Physical Medicine and Rehabilation, Temple University Hospital, Philadelphia, PA
| | - Ernesto Cruz
- Department of Physical Medicine and Rehabilation, Temple University Hospital, Rock Pavilion, Lower Level, 3401 North Broad St, Philadelphia, PA 19140.,Department of Physical Medicine and Rehabilation, Temple University Hospital, Philadelphia, PA
| |
Collapse
|
19
|
Magsi S, Zafar A. Malignant Posterior Reversible Encephalopathy Syndrome-An Exacting Challenge for Neurocritical Care Physicians. Neurohospitalist 2017; 7:196-199. [PMID: 28974999 DOI: 10.1177/1941874416688989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report a case of malignant posterior reversible encephalopathy syndrome (PRES) in a 62-year-old Caucasian female with a complex medical history and comorbidities admitted for bowel resection and lysis of iatrogenic bowel adhesions and enterocutaneous fistulas. Postoperatively, the patient developed sudden bilateral visual loss with no other neurologic deficits. Computed tomography scan showed very severe PRES-like changes, confirmed on magnetic resonance imaging (MRI). Systolic blood pressure remained around 170 mm HG. The patient was obtunded and remained unresponsive after MRI, with minimal response and a deteriorating clinical condition. The patient was given hyperosmolar therapy with a mannitol bolus. She recovered well with near resolution of imaging findings.
Collapse
|
20
|
Nowacki M, Nazarewski Ł, Kloskowski T, Tyloch D, Pokrywczyńska M, Pietkun K, Jundziłł A, Tyloch J, Habib SL, Drewa T. Novel surgical techniques, regenerative medicine, tissue engineering and innovative immunosuppression in kidney transplantation. Arch Med Sci 2016; 12:1158-1173. [PMID: 27695507 PMCID: PMC5016594 DOI: 10.5114/aoms.2016.61919] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 02/08/2015] [Indexed: 01/09/2023] Open
Abstract
On the 60th anniversary of the first successfully performed renal transplantation, we summarize the historical, current and potential future status of kidney transplantation. We discuss three different aspects with a potential significant influence on kidney transplantation progress: the development of surgical techniques, the influence of regenerative medicine and tissue engineering, and changes in immunosuppression. We evaluate the standard open surgical procedures with modern techniques and compare them to less invasive videoscopic as well as robotic techniques. The role of tissue engineering and regenerative medicine as a potential method for future kidney regeneration or replacement and the interesting search for novel solutions in the field of immunosuppression will be discussed. After 60 years since the first successfully performed kidney transplantation, we can conclude that the greatest achievements are associated with the development of surgical techniques and with planned systemic immunosuppression.
Collapse
Affiliation(s)
- Maciej Nowacki
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Chair of Surgical Oncology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Łukasz Nazarewski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Kloskowski
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Dominik Tyloch
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Marta Pokrywczyńska
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Katarzyna Pietkun
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Arkadiusz Jundziłł
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Janusz Tyloch
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
| | - Samy L. Habib
- Department of Geriatrics, Geriatric Research, Education, and Clinical Center, South Texas Veterans Healthcare System, San Antonio, TX, USA
- Department of Cellular and Structural Biology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Tomasz Drewa
- Chair of Urology, Department of Regenerative Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
- Department of General and Oncological Urology, Nicolaus Copernicus Hospital, Torun, Poland
| |
Collapse
|
21
|
Tang JH, Tian JM, Sheng M, Hu SY, Li Y, Zhang LY, Gu Q, Wang Q. Study of Posterior Reversible Encephalopathy Syndrome in Children With Acute Lymphoblastic Leukemia After Induction Chemotherapy. J Child Neurol 2016; 31:279-84. [PMID: 26060305 DOI: 10.1177/0883073815589758] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 04/21/2015] [Indexed: 12/16/2022]
Abstract
Increasing occurrence of posterior reversible encephalopathy syndrome has been reported in children with acute lymphoblastic leukemia. However, the etiology of posterior reversible encephalopathy syndrome is not clear. To study the possible pathogenetic mechanisms and treatment of this complication, we reported 11 cases of pediatric acute lymphoblastic leukemia who developed posterior reversible encephalopathy syndrome after induction chemotherapy. After appropriate treatment, the clinical symptoms of posterior reversible encephalopathy syndrome in most cases disappeared even though induction chemotherapy continued. During the 1-year follow-up, no recurrence of posterior reversible encephalopathy syndrome was observed. Although the clinical and imaging features of posterior reversible encephalopathy syndrome may be diverse, posterior reversible encephalopathy syndrome should be recognized as a possible important complication of acute lymphoblastic leukemia when neurologic symptoms appear. In line with previous reports, our study also indicated that posterior reversible encephalopathy syndrome was reversible when diagnosed and treated at an early stage. Thus, the occurrence of posterior reversible encephalopathy syndrome should be considered and investigated to optimize the early induction scheme of acute lymphoblastic leukemia treatment.
Collapse
Affiliation(s)
- Ji-Hong Tang
- Department of Neurology, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Jian-Mei Tian
- Department of Internal Medicine, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Mao Sheng
- Radiology Department, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Shao-Yan Hu
- Department of Hematology and Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Yan Li
- Department of Neurology, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Li-Ya Zhang
- Department of Hematology and Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Qing Gu
- Department of Neurology, Children's Hospital Affiliated to Soochow University, Suzhou, China
| | - Qi Wang
- Radiology Department, Children's Hospital Affiliated to Soochow University, Suzhou, China
| |
Collapse
|
22
|
Posterior Reversible Encephalopathy Syndrome After Transplantation: a Review. Mol Neurobiol 2015; 53:6897-6909. [PMID: 26666662 DOI: 10.1007/s12035-015-9560-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 11/29/2015] [Indexed: 12/29/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disease. Recently, an increase in the number of transplantations has led to more cases being associated with PRES than what was previously reported. Calcineurin inhibitors (CNIs) are major risk factors for PRES in posttransplantation patients. The mechanisms of the development of PRES remain to be unclear. The typical clinical symptoms of PRES include seizures, acute encephalopathy syndrome, and visual symptoms. The hyperintense signal on fluid-attenuated inversion recovery image is the characteristic of the imaging appearance in these patients. In addition, other abnormal signals distributed in multiple locations are also reported in some atypical cases. Unfortunately, PRES is often not recognized or diagnosed too late due to complicated differential diagnoses, such as ischemic stroke, progressive multifocal leukoencephalopathy, and neurodegenerative diseases. Thus, this review emphasizes the importance of considering the possibility of PRES when neurological disturbances appear after solid organ transplantation or hematopoietic cell transplantation. Moreover, this review demonstrates the molecular mechanisms of PRES associated with CNIs after transplantation, which aims to help clinicians further understand PRES in the transplantation era.
Collapse
|
23
|
Nguyen TA, Krakowski AC, Naheedy JH, Kruk PG, Fallon Friedlander S. Imaging Pediatric Vascular Lesions. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2015; 8:27-41. [PMID: 26705446 PMCID: PMC4689509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Vascular anomalies are commonly encountered in pediatric and dermatology practices. Most of these lesions are benign and easy to diagnose based on history and clinical exam alone. However, in some cases the diagnosis may not be clear. This may be of particular concern given that vascular anomalies may occasionally be associated with an underlying syndrome, congenital disease, or serious, life-threatening condition. Defining the type of vascular lesion early and correctly is particularly important to determine the optimal approach to management and treatment of each patient. The care of pediatric patients often requires collaboration from a multitude of specialties including pediatrics, dermatology, plastic surgery, radiology, ophthalmology, and neurology. Although early characterization of vascular lesions is important, consensus guidelines regarding the evaluation and imaging of vascular anomalies does not exist to date. Here, the authors provide an overview of pediatric vascular lesions, current classification systems for characterizing these lesions, the various imaging modalities available, and recommendations for appropriate imaging evaluation.
Collapse
Affiliation(s)
- Tuyet A. Nguyen
- Albert Einstein College of Medicine, Bronx, New York
- Rady Children’s Hospital, San Diego, California
| | - Andrew C. Krakowski
- Rady Children’s Hospital, San Diego, California
- DermOne, LLC, West Conshohocken, Pennsylvania
| | - John H. Naheedy
- Rady Children’s Hospital, San Diego, California
- University of California, San Diego
| | - Peter G. Kruk
- Rady Children’s Hospital, San Diego, California
- University of California, San Diego
| | | |
Collapse
|
24
|
Bax K, Tijssen J, Rieder MJ, Filler G. Rapid Resolution of Tacrolimus Intoxication–Induced AKI With a Corticosteroid and Phenytoin. Ann Pharmacother 2014; 48:1525-8. [DOI: 10.1177/1060028014546184] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objective: To report a novel approach to the management of tacrolimus intoxication that leads to rapid normalization of serum tacrolimus concentrations. Case Summary: A 9-year-old female renal transplant recipient developed a severe tacrolimus intoxication as a result of prolonged diarrhea, which resulted in acute kidney injury, severe dehydration, and neurological symptoms. We used a combination of intravenous steroids and intravenous phenytoin to normalize the tacrolimus level from 32 to 5 ng/mL in less than 24 hours, with complete resolution of symptoms and signs. Discussion: Tacrolimus intoxication is a rare event but may result in life-threatening complications. Treatment recommendations beyond holding the drug and enzyme induction with phenytoin or phenobarbital are elusive. This approach leads to a relatively slow normalization of the tacrolimus level over 72 hours. The authors hypothesized that additional induction of the p-glycoprotein through steroids was synergistic. Conclusions: The combination of phenytoin and a corticosteroid may be an effective approach that leads to rapid normalization of severely elevated tacrolimus levels.
Collapse
Affiliation(s)
- Kevin Bax
- University of Western Ontario, Department of Paediatrics, London, ON, Canada
- Children’s Hospital, London Health Sciences Centre, London, ON, Canada
| | - Janice Tijssen
- University of Western Ontario, Department of Paediatrics, London, ON, Canada
- Children’s Hospital, London Health Sciences Centre, London, ON, Canada
| | - Michael J. Rieder
- University of Western Ontario, Department of Paediatrics, London, ON, Canada
- Children’s Hospital, London Health Sciences Centre, London, ON, Canada
| | - Guido Filler
- University of Western Ontario, Department of Paediatrics, London, ON, Canada
- Children’s Hospital, London Health Sciences Centre, London, ON, Canada
| |
Collapse
|