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      A Case of Tacrolimus-Induced Posterior Reversible Encephalopathy Syndrome Initially Presenting as a Bilateral Optic Neuropathy

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          Abstract

          Purpose: To report a case of asymmetric bilateral optic neuropathy in a patient receiving tacrolimus for immunosuppression after kidney transplantation with subsequent stroke-like symptoms of posterior reversible encephalopathy syndrome (PRES). Method: Case report. In a 54-year-old Hispanic male receiving tacrolimus after orthotropic kidney transplantation, serial ophthalmologic examinations, laboratory studies, and imaging were performed. Results: The patient had deterioration of vision in the left eye with subclinical optic neuropathy in the right eye, with clinical features resembling ischemic optic neuropathy. Additionally, he developed a change in mental state with weakness of extremities. After the cessation of tacrolimus, the visual loss remained but the other neurologic symptoms resolved. Conclusion: Tacrolimus may be associated with optic neuropathy and PRES at the initial presentation to an ophthalmologist.

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          Tacrolimus-associated posterior reversible encephalopathy syndrome after allogeneic haematopoietic stem cell transplantation.

          C Ippoliti, Raymond Wong, Marcos Lima … (2003)
          Neurotoxicity is a significant complication of the use of tacrolimus. From April 1998 to December 2001, we identified 10 patients (six women, four men) who developed 11 episodes of tacrolimus-associated posterior reversible encephalopathy syndrome (PRES) after allogeneic haematopoietic stem cell transplantation for haematological malignancies. The diagnosis was made by characteristic clinical findings (mental status changes, seizures, neurological deficits) with the exclusion of other causes and characteristic imaging findings. The median age was 35.5 years (range 19-57 years). Seven patients received a matched-unrelated donor transplant and three received a cord blood transplant. The overall incidence of PRES was 1.6%, while the incidence in matched-unrelated, mismatched-related and cord blood transplants was 3.5%, 4.9% and 7.1% respectively. Mental status changes, cognitive deficits, seizures and lethargy were the most common clinical findings. Eight of 10 patients had characteristic findings of hyperintensity of the white matter on T2-weighted images and FLAIR (fluid-attenuated inversion recovery) sequence on magnetic resonance imaging of the brain. Serum tacrolimus levels were within the therapeutic range in most patients. Tacrolimus treatment was continued (n = 4) or temporarily withheld (n = 7) for 1-14 d. One patient was changed to cyclosporine. In most patients, subsequent treatment with tacrolimus was well tolerated without recurrence of neurotoxicity.
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            Corticosteroids and immunosuppressive therapy influence the result of QuantiFERON TB Gold testing in inflammatory bowel disease patients.

            Stefan Schreiber, Ulf Helwig, Michael Müller … (2012)
            Latent tuberculosis infection is detected by the tuberculin skin test before treating with anti-Tumour-Necrosis factor alpha (anti TNFα) reagents. More accurate are Interferon gamma release assays (IFNγ release assays) to identify patients with latent tuberculosis. Because of a positive control in this assay, it is possible to identify those patients in which a result of tuberculosis testing is not available due to a lack of stimulation capacity of lymphocytes (indeterminate result). Patients suffering from IBD are often treated with immunosuppressive agents, which may influence the results of tuberculosis testing. The aim is to investigate the influence of immunosuppressive agents on the outcome of IFNγ-release assay. 50 consecutive patients were documented before introducing anti-TNF-treatment in this single centre study between April 2009 and April 2010. Data of INFγ release assay for latent tuberculosis, skin test and laboratory data and current medication were enrolled. For the period of one year data of 45 consecutive patients was available for statistical analysis. 24 patients out of 45 (corresponding to 53.3%) received at least low doses of corticoid treatment and 27 patients out of 45 (corresponding to 60.0%) received immunosuppressive agents. 13 patients out of 45 (corresponding to 28.9%) had an indeterminate result of the QuantiFERON test. A correlation between the indeterminate result and combination therapy of corticosteroids was found. The concomitant therapy of immunosuppressive agents lead to a lower IFN release but no significance was found. Steroid treatment and further combination therapy with immunosuppressive agents lead to a high risk of indeterminate QuantiFERON test. Copyright © 2011 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.
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              A case of bilateral optic neuropathy in a patient on tacrolimus (FK506) therapy after liver transplantation.

              Paul Brazis, James Spivey, James Bolling … (2000)
              To report a case of bilateral optic neuropathy in a patient receiving tacrolimus (FK 506, Prograf; Fujisawa USA, Inc, Deerfield, Illinois) for immunosuppression after orthotropic liver transplantation. Case report. In a 58-year-old man receiving tacrolimus after orthotropic liver transplantation, serial neuro-ophthalmologic examinations and laboratory studies were performed. The patient had episodic deterioration of vision in both eyes, with clinical features resembling ischemic optic neuropathies. Deterioration of vision occurred despite discontinuation of the tacrolimus. Tacrolimus and other immunosuppressive agents may be associated with optic nerve toxicity.
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                Author and article information

                Journal
                Journal ID (publisher-id): COP
                Journal ID (pmc): COP
                Journal ID (doi): 10.1159/issn.1663-2699
                Title: Case Reports in Ophthalmology
                Publisher: S. Karger AG
                ISSN (Electronic): 1663-2699
                Publication date Subscription-year: 2019
                Publication date Collection: January - April 2019
                Publication date (Electronic): 23 April 2019
                Volume: 10
                Issue: 1
                Pages: 140-144
                Affiliations
                [_a] aDepartment of Ophthalmology, Temple University Hospital, Philadelphia, Pennsylvania, USA
                [_b] bDepartment of Ophthalmology, Veterans Affairs Medical Center, Bay Pines, Florida, USA
                Author notes
                *Sumana S. Kommana, MD, Department of Ophthalmology, Temple University Hospital, 3401 N. Broad Street, 6th floor, Zone C, Parkinson, Philadelphia, PA 19401 (USA), E-Mail sumana.kommana@tuhs.temple.edu
                Author information
                https://orcid.org/0000-0001-6663-9147
                Article
                Publisher ID: 496916 Other ID: Case Rep Ophthalmol 2019;10:140–144
                DOI: 10.1159/000496916
                SO-VID: 7608d751-8490-4fa1-ab74-3c1a0203c125
                Copyright © © 2019 The Author(s). Published by S. Karger AG, Basel
                License:

                This article is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC). Usage and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 13 August 2018
                Date accepted : 14 January 2019
                Page count
                Figures: 3, Pages: 5
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Vision sciences,Ophthalmology & Optometry,Pathology
                Keywords: Tacrolimus,Optic neuropathy,Medication toxicity,Posterior reversible encephalitis syndrome
                Data availability:
                ScienceOpen disciplines: Vision sciences, Ophthalmology & Optometry, Pathology
                Keywords: Tacrolimus, Optic neuropathy, Medication toxicity, Posterior reversible encephalitis syndrome

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