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Case Reports
. 2023 Jan 25:1:1089995.
doi: 10.3389/frtra.2022.1089995. eCollection 2022.

Pre-engraftment neurological impairment in allogeneic stem cell transplant: A case report of atypical posterior reversible encephalopathy syndrome with pontine involvement

Andrea Acerbis  1   2 , Giorgio Orofino  1   2 , Edoardo Campodonico  1   2 , Anna Del Poggio  3 , Elisabetta Xue  1 , Francesca di Matteo  2   3 , Greta Spelta  2   3 , Alessandro Bruno  1   2 , Andrea Falini  2   3 , Fabio Ciceri  1   2 , Jacopo Peccatori  1 , Raffaella Greco  1   2
Affiliations
Case Reports

Pre-engraftment neurological impairment in allogeneic stem cell transplant: A case report of atypical posterior reversible encephalopathy syndrome with pontine involvement

Andrea Acerbis et al. Front Transplant. .

Abstract

In the present report, we describe the case of a 59-year-old female who developed pre-engraftment multiple organ failure (MOF) after allogeneic hematopoietic stem cell transplant (HSCT), followed a few days later by a cohort of neurological symptoms leading to a diagnosis of posterior reversible encephalopathy syndrome (PRES). The diagnosis was achieved by excluding more frequent entities associated with neurological symptoms in HSCT and supported by compatible magnetic resonance imaging (MRI) findings, with remarkably interesting less frequent pontine involvement. GvHD prophylaxis, including sirolimus and mycophenolate mofetil (MMF), was discontinued, while carefully controlling blood pressure. In addition, high-dose steroids were employed. After 2 weeks, the neurological symptoms abated, and follow-up MRI showed a complete regression of neurological alterations, confirming the diagnostic hypothesis of PRES.

Keywords: PRES—posterior reversible encephalopathy syndrome; allogeneic; bone marrow translation (BMT); neuroimaging; neurological complications.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Possible etiologies of neurological complications at different time points (during conditioning, engraftment phase, and after 100 days) in the setting of allogeneic HSCT. BMT, bone marrow transplantation; GvHD, graft versus host disease; Pres, posterior reversible encephalopathy.
Figure 2
Figure 2
Possible differential diagnosis and diagnostic algorithm of neurological complications in patients undergoing allogeneic HSCT. PCR, polymerase chain reaction; HSV 6, human herpes virus 6; EBV, Epstein–Barr virus; CMV, cytomegalovirus; HSV 1/2, human herpes virus 1/2; EEG, electroencephalogram; CNS, central nervous system.
Figure 3
Figure 3
Schematic representation of the case. BMT, bone marrow transplant; MRI, magnetic resonance imaging; MMF, mycophenolate mofetil.
Figure 4
Figure 4
Brain MRI: (A–C) FLAIR images; (D) ADC map; (E,F) T2 weighted images. (A,D) first MRI shows areas of a hyperintense signal in FLAIR at the level of the occipital poles bilaterally with a greater extension to the right one with high AD values consistent with edema; (B,E): second MRI shows a resolution of FLAIR hyperintensities referable to vasogenic edema in the bilateral polar occipital cortico-subcortical area; on the other hand, diffuse centropontine alteration in T2/FLAIR sequences (FLAIR not shown) appears; (C,F) third MRI shows a complete regression of the whole alteration both in the supratentorial posterior white matter and in the pons. MRI, magnetic resonance imaging; FLAIR, fluid attenuated inversion recovery; ADC map, apparent diffusion coefficient map; AD value, ADded value.
See this image and copyright information in PMC

References

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