Posterior Reversible Encephalopathy Syndrome after Heart Transplantation: Diagnosis and Immunosuppressive Therapy

Abstract

Posterior reversible encephalopathy syndrome, an infrequent neurotoxicity associated with the use of tacrolimus, was first described in 1996, as a reversible syndrome manifested by headache, altered mental function, seizures, and visual disturbances. We describe the case of a 37-year-old woman who developed neurologic symptoms consistent with encephalopathy after treatment with tacrolimus, which was prescribed to maintain immunosuppression after orthotopic heart transplantation. This report also discusses the imaging methods used in the diagnosis of posterior reversible encephalopathy and highlights the difficulty of maintaining immunosuppression and managing medication-related adverse effects, while taking into account the risk of acute rejection after transplantation.

Keywords: Brain diseases/diagnostic imaging; drug therapy, combination; graft rejection/heart transplantation/adverse effects; immunosuppressive agents/therapeutic use; nervous system diseases/chemically induced; tacrolimus/adverse effects/therapeutic use; treatment outcome.

Fig. 1.

Magnetic resonance images. A) Upon the patient's presentation with seizures, multiple areas of high signal intensity within the cortex of the bilateral frontal and parietal lobes were seen, along with subtle signs of abnormality in the temporal and occipital cortices. B) Previous findings resolved after discontinuation of tacrolimus therapy, which correlated with the resolution of symptoms.

Fig. 2.

Drawing shows the pathophysiology of endothelium damage contributing to the development of posterior reversible encephalopathy syndrome.

Fig. 3.

Diffusion-weighted magnetic resonance images in patients with posterior reversible encephalopathy syndrome show findings consistent with vasogenic edema: A) holohemispheric watershed pattern; B) superior frontal sulcus pattern; C) dominant parietal-occipital pattern; and D) partial or asymmetric expression of the primary patterns. (Reprinted with permission from Arzanian MT, et al.)