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 abnormal-ities 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.

Tacrolimus-induced posterior reversible encephalopathy syndrome following liver transplantation

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 Tcell 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.

Posterior reversible encephalopathy syndrome and heart failure tacrolimus-induced after liver transplantation: A case report

BACKGROUND Patients undergoing liver transplantation can develop posterior reversible encephalopathy syndrome(PRES)and acute heart failure(HF)in the postoperative period.But PRES with HF caused by tacrolimus has rarely been described.CASE SUMMAR A 40-year-old female patient who had a normal preoperative cardiac and neural evaluation developed PRES with acute heart failure tacrolimus-induced after liver transplantation.The challenges associated with both diagnosis and management in the setting of a newly implanted graft are discussed.CONCLUSION Tacrolimus can induce neurotoxicity and then cardiac toxicity.Magnetic resonance imaging,echocardiography,and increased brain natriuretic peptide may be predictive of post-operative PRES with acute heart failure.Further investigations are necessary to verify this finding.

Posterior reversible encephalopathy syndrome in a patient with metastatic breast cancer:A case report

BACKGROUND Posterior reversible encephalopathy syndrome(PRES)is a neurotoxic encephalopathic state with clinical symptoms such as headache,altered consciousness,visual disturbances,and seizures.Vasogenic edema occurs predominantly in the posterior occipital and parietal lobes of the brain.PRES is caused by various diseases,and its mechanism remains unclear.However,it can be easily diagnosed based on characteristic lesions on magnetic resonance imaging.CASE SUMMARY A 51-year-old woman with unremarkable past medical history presented with progressively worsening back pain since 2 mo.Physical examinations revealed paralumbar muscle tenderness,a large lesion on the right breast and several masslike lesions on both breasts.The blood pressure(BP)was elevated(150/90 mmHg),and did not respond to antihypertensive medication.On the seventh day of hospitalization,she exhibited a confused mental status and generalized tonicclonic seizures.On magnetic resonance imaging,bilateral cortical and subcortical edema of the occipital lobes,suggestive of PRES,was observed.The serum calcium was 15.8 mg/dL.After two days of treatment with nicardipine,elcatonin,and zolendronic acid,her BP was 130/91 mmHg and serum calcium was 10.1 mg/dL.The patient regained consciousness and her mental status improved.Fluorodeoxyglucose-positron emission tomography revealed right breast cancer with extensive metastases.CONCLUSION Although rare,hypercalcemia can lead to PRES by causing uncontrolled hypertension.Prompt diagnosis can help prevent severe mental disturbances and even death.

Postpartum posterior reversible encephalopathy syndrome secondary to preeclampsia and cerebrospinal fluid leakage:A case report and literature review

BACKGROUND Postpartum posterior reversible encephalopathy syndrome(PRES) is not uncommon.Its mechanisms and risk factors are not clear.CASE SUMMARY A 28-year-old woman underwent cesarean section but had inadvertent dural puncture during epidural anesthesia.To manage the symptoms of intracranial hypotension,crystalloid fluid was infused.However,the patient developed postpartum preeclampsia and PRES.The patient was treated with diazepam and dehydration therapy.The signs of cerebral lesions on magnetic resonance imaging disappeared on postpartum day 7.CONCLUSION Postpartum preeclampsia and PRES can develop concomitantly.Treating postdural puncture headaches with infusion of crystalloid fluid may precipitate the development of PRES.

Posterior reversible encephalopathy syndrome in alcoholic hepatitis:Hepatic encephalopathy a common theme

Posterior reversible encephalopathy syndrome(PRES) is a neuro-radiologic diagnosis that has become more widely recognized and reported over the past few decades. As such, there are a number of known risk factors that contribute to the development of this syndrome, including volatile blood pressures, renal failure, cytotoxic drugs, autoimmune disorders, pre-eclampsia, and eclampsia. This report documents the first reported case of PRES in a patient with severe alcoholic hepatitis with hepatic encephalopathy and delves into a molecular pathophysiology of the syndrome.

Autoimmune encephalitis with posterior reversible encephalopathy syndrome:A case report

BACKGROUND Posterior reversible encephalopathy syndrome(PRES)is a neuroimaging-based syndrome and is associated with multifocal vasogenic cerebral edema.Patients with PRES frequently demonstrate headache,seizure,encephalopathy,altered mental function,visual loss and so on.We here report a patient who showed persistent neurologic deficits after PRES and was ultimately diagnosed with autoimmune encephalitis(AE).CASE SUMMARY This case exhibits a rare imaging manifestation of anti-casper 2 encephalitis which was initially well-matched with PRES and associated vasogenic edema.CONCLUSION AE should be further considered when the etiology,clinical manifestations,and course of PRES are atypical.

Oral cyclophosphamide-induced posterior reversible encephalopathy syndrome in a patient with ANCA-associated vasculitis:A case report

BACKGROUND Posterior reversible encephalopathy syndrome(PRES)manifests many neurological symptoms with typical features on neuroimaging studies and has various risk factors.Cyclophosphamide is one of the therapeutic agents for antineutrophil cytoplasmic antibody(ANCA)-associated vasculitis.Cyclophosphamide as the sole cause of PRES has been reported in only a few cases.Herein,we report a unique case of early-onset oral cyclophosphamide-induced PRES in a patient with ANCA-associated vasculitis.CASE SUMMARY A 73-year-old man was transferred to our hospital for sepsis due to acute cholangitis.He had already received hemodialysis for two weeks due to septic acute kidney injury.His azotemia was not improved after sepsis resolved and perinuclear-ANCA was positive.Kidney biopsy showed crescentic glomerulonephritis.Alveolar hemorrhage was observed on bronchoscopy.He was initially treated with intravenous methylprednisolone and plasma exchange for one week.And then,two days after adding oral cyclophosphamide,the patient developed generalized tonic-clonic seizures.We diagnosed PRES by Brain magnetic resonance imaging(MRI)and electroencephalography.Seizures were controlled with fosphenytoin 750 mg.Cyclophosphamide was suspected to be the cause of PRES and withdrawal.His mentality was recovered after seven days and brain MRI showed normal state after two weeks.CONCLUSION The present case shows the possibility of PRES induction due to short-term use of oral cyclophosphamide therapy.Physicians should carefully monitor neurologic symptoms after oral cyclophosphamide administration in elderly patients with underlying diseases like sepsis,renal failure and ANCA-associated vasculitis.

Comment on “Posterior reversible encephalopathy syndrome in a patient with metastatic breast cancer: A case report”

Posterior reversible encephalopathy syndrome(PRES)is a neurotoxic encephalopathic state,manifesting clinical symptoms of headache,altered consciousness,visual disturbances,and seizures.Although several diseases have been identified as causative of PRES,the underlying mechanism remains unclear.Song et al recently published“Posterior reversible encephalopathy syndrome(PRES)in a patient with metastatic breast cancer:A case report“in the World Journal of Clinical Cases,highlighting and discussing the role of hypercalcemia in PRES as related to uncontrolled hypertension.To build upon this case description,we provide further insight into the possible underlying mechanisms of PRES through this commentary.

Posterior reversible encephalopathy syndrome following uneventful clipping of an unruptured intracranial aneurysm:A case report

BACKGROUND Posterior reversible encephalopathy syndrome(PRES)is characterized mainly by occipital and parietal lobe involvement,which can be reversible within a few days.Herein,we report a rare case of PRES that developed after craniotomy for an unruptured intracranial aneurysm(UIA).CASE SUMMARY A 59-year-old man underwent clipping surgery for the treatment of UIA arising from the left middle cerebral artery.Clipping surgery was performed uneventfully,and he regained consciousness quickly immediately after the surgery.At the 4th hour after surgery,he developed a disorder of consciousness and aphasia.Magnetic resonance imaging revealed cortical and subcortical T2/FLAIR hyperintensities in the parietal,occipital,and frontal lobes ipsilaterally,without restricted diffusion,consistent with unilateral PRES.With conservative treatment,his symptoms and radiological findings almost completely disappeared within weeks.In our case,the important causative factor of PRES was suspected to be a sudden increase in cerebral perfusion pressure associated with temporary M1 occlusion.CONCLUSION Our unique case highlights that,to our knowledge,this is the second report of PRES developing after craniotomy for the treatment of UIA.Surgeons must keep PRES in mind as one of the causes of perioperative neurological abnormality following clipping of an UIA.

A Typical Case of Posterior Reversible Encephalopathy Syndrome Associated with Postpartum Eclampsia-HELLP Syndrome

Background: Posterior reversible encephalopathy syndrome (PRES) is a reversible syndrome characterized by seizures, headache, altered mentation, and loss of vision associated with white matter changes on imaging. Case: A 37-year-old multigravida woman had a severe, immediate postpartum eclampsia-HELLP syndrome (hemolysis, elevated liver enzyme levels, low platelet count) with PRES characterized by generalized seizures and altered mental status. Magnetic resonance brain imaging showed high-intensity lesions in non-posterior portions including the frontal lobe and cingulated gyrus, which resolved completely after 2 weeks along with complete symptom regression. Conclusions: Cases of postpartum PRES without involvement of posterior brain regions after eclampsia-HELLP syndrome are very rare. Patients with PRES do not always show typical manifestations. The importance of a prompt diagnosis is emphasized, as is the crucial role of rapid blood pressure reduction.

Posterior reversible encephalopathy syndrome in patients with hematologic tumor confers worse outcome

Background:This study aimed to evaluate the clinical features of posterior reversible encephalopathy syndrome(PRES)in children.Methods:The medical records of 31 patients from five medical centers who were diagnosed with PRES from 2001 to 2013 were retrospectively analyzed.In the 31 patients,16 were males,and 15 females,with a median age of 7 years(3-12 years).Patients younger than 10 years accounted for 74.2%of the 31 patients.Results:Seizure,the most common clinical sign,occurred in 29 of the 31 patients.Visual disturbances were also observed in 20 patients.Cerebral imaging abnormalities were bilateral and predominant in the parietal and occipital white matter.In this series,three patients died in the acute phase of PRES.One patient had resolution of neurologic presentation within one week,but no apparent improvement in radiological abnormalities was observed at eight months.One patient showed gradual recovery of both neurologic presentation and radiological abnormalities during follow-up at eight months.One patient developed long-term cortical blindness.All of the PRES patients with hematologic tumor had a worse prognosis than those without hematologic tumor.Conclusions:Seizure is a prevalent characteristic of children with PRES.Poor prognosis can be seen in PRES patients with hematologic tumor.

Posterior reversible encephalopathy syndrome due to seronegative systemic lupus erythematosus

Posterior reversible encephalopathy syndrome(PRES)is a neurotoxic state coupled with a unique computed tomography or magnetic resonance imaging(MRI)appearance.Recognized in the setting of a number of complex conditions(preeclampsia/eclampsia,allogeneic bone marrow transplantation,organ transplantation,autoimmune disease and high-dose chemotherapy)in the imaging,clinical and laboratory features of this toxic state are becoming better elucidated.We are presenting a case of PRES due to seronegative systemic lupus erythematosus,with MRI findings of diffuse vasogenic edema.

Neurological complications of hematopoietic cell transplantation in children and adults

Hematopoietic cell transplantation（HCT） is widely performed for neoplastic and non-neoplastic diseases. HCT involves intravenous infusion of hematopoietic progenitor cells from human leukocyte antigen（HLA）-matched donor（allogeneic） or from the patient（autologous）. Before HCT, the patient is prepared with high dose chemotherapy and/or radiotherapy to destroy residual malignant cells and to reduce immunologic resistance. After HCT, chemotherapy is used to prevent graft rejection and graft versus host disease（Gv HD）. Neurological complications are related to the type of HCT, underlying disease, toxicity of the conditioning regimens, immunosuppression caused by conditioning regimens, vascular complications generated by thrombocytopenia and/or coagulopathy, Gv HD and inappropriate immune response. In this review, neurological complications are presented according to time of onset after HCT：（1） early complications（in the first month）-related to harvesting of stem cells, during conditioning（drug toxicity, posterior reversible encephalopathy syndrome）, related to pancytopenia,（2） intermediate phase complications（second to sixth month）-central nervous system infections caused by prolonged neutropenia and progressive multifocal leukoencephalopathy due to JC virus,（3） late phase complications（after sixth month）-neurological complications of Gv HD, second neoplasms and relapses of the original disease.

Neurological Manifestations of Takayasu Arteritis

Objective To investigate the clinical neurological manifestations of Takayasu arteritis (TA). Methods A retrospective study was conducted with 63 consecutive TA cases admitted to Peking Union Medical College Hospital from January 2009 to May 2010. All the patients fulfilled the diagnostic criteria of TA by the American College of Rheumatology. Among the 63 TA patients, 27 with neurological manifestations were included in the present study. All the patients were evaluated using standardized neurological examination, sonography, computed tomography (CT) angiography, and cerebral CT or magnetic resonance imaging. Results Dizziness and visual disturbance were the most common symptoms, which occurred in 20 (74.1%) and 16 (59.3%) patients respectively. Another common symptom was headache, observed in 15 (55.6%) patients. Six (22.2%) patients had suffered from ischemic stroke; 7 (25.9%) patients had epileptic seizures. Two (7.4%) patients were diagnosed as reversible posterior encephalopathy syndrome (RPES) based on typical clinical and imaging manifestations. Conclusions Neurological manifestations are common symptoms in TA patients in the chronic phase, including dizziness, visual disturbance, headache, ischemic stroke, seizures, and some unusual ones such as RPES. We suggested RPES be included into the differential diagnosis of acute neurological changes in TA.

Belimumab shows promise in neuropsychiatric lupus:Another challenge to find the offender

Introduction:Agents that can be used for the treatment of neuropsychiatric lupus(NPSLE)are lacking in the therapeutic armamentarium.Belimumab is a monoclonal antibody targeting the B-cell activating factor(BAFF)and is approved by the US Food and Drug Administration as an additional treatment for systemic lupus erythematosus patients with persistent disease activity and lupus nephritis(LN);however,severe active central nervous system manifestations were excluded.Case Report:We report on a treatment-naïve LN patient with refractory NPSLE complicated with progressive posterior reversible encephalopathy syndrome(PRES)who was successfully treated via the combination of mycophenolate and belimumab,resulting in reversal of persistent headache and neuroradiologic manifestations.Conclusion:Research on this topic could be relevant for identifying a possible correlation between BAFF and psychiatric NPSLE manifestations.