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Tacrolimus-associated posterior reversible encephalopathy syndrome (PRES) in a bone marrow transplant recipient. G. Ntetskas, E. Spanou, V. Papastergiou,

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Presentation on theme: "Tacrolimus-associated posterior reversible encephalopathy syndrome (PRES) in a bone marrow transplant recipient. G. Ntetskas, E. Spanou, V. Papastergiou,"— Presentation transcript:

1 Tacrolimus-associated posterior reversible encephalopathy syndrome (PRES) in a bone marrow transplant recipient. G. Ntetskas, E. Spanou, V. Papastergiou, M. Stampori, E. Asonitis, E. Anastasiou, F. Alourda,F. Lambrianou, A. Kotis, S. Karatapanis First Department of Internal Medicine, General Hospital of Rhodes, First Department of Internal Medicine, General Hospital of Rhodes,

2 Posterior Reversible Encephalopathy Syndrome (PRES) Clinicoradiological entity Clinicoradiological entity Described by Hinchey et al in 1996 Described by Hinchey et al in 1996 Reversible ischemia of the posterior cerebral vasculature Reversible ischemia of the posterior cerebral vasculature Vasogenic edema (parietal-occipital region) Vasogenic edema (parietal-occipital region)

3 Posterior Reversible Encephalopathy Syndrome (PRES) Cerebral imaging abnormalities Cerebral imaging abnormalities (often symmetric and predominate in the posterior white matter) Neurologic features Neurologic features (consciousness impairment, seizures, headaches, visual abnormalities, nausea/vomit, focal neurological signs)

4 Posterior Reversible Encephalopathy Syndrome (PRES) Unknown incidence (rare) Unknown incidence (rare) Most commonly occur in middle-aged adults (39-47 years) Most commonly occur in middle-aged adults (39-47 years) Female predominance Female predominance Associated comorbidities: Hypertension, bone marrow or solid organ transplantation, chronic renal failure, medications, eclampsia. Associated comorbidities: Hypertension, bone marrow or solid organ transplantation, chronic renal failure, medications, eclampsia. Usually reversible once the cause is removed Usually reversible once the cause is removed Need for mechanical ventilation in 35-40% Need for mechanical ventilation in 35-40% Permanent neurological impairment or death (up to 15%) may occur in a minority of patients Permanent neurological impairment or death (up to 15%) may occur in a minority of patients

5 Posterior Reversible Encephalopathy Syndrome (PRES) Pathogenesis is unknown Pathogenesis is unknown Hypertensive PRES: failure of cerebrovascular autoregulation Hypertensive PRES: failure of cerebrovascular autoregulation Non-hypertensive PRES: autoimmune or immune response to various stimuli Non-hypertensive PRES: autoimmune or immune response to various stimuli There are no consensual guidelines to validate diagnosis of PRES

6 Female Female 55 years old 55 years old History of acute myeloid leukemia treated with bone marrow transplantation 12 months ago History of acute myeloid leukemia treated with bone marrow transplantation 12 months ago Since the last 3 months the patient was under Tacrolimus to prevent graft-vs-host disease. Since the last 3 months the patient was under Tacrolimus to prevent graft-vs-host disease. Case presentation

7 Presentation to the ER Altered mental status Altered mental status Confused Confused Disoriented Disoriented GCS score was 10 (eye response to verbal command, incomprehensive speech, purposeful movements to painful stimulus) GCS score was 10 (eye response to verbal command, incomprehensive speech, purposeful movements to painful stimulus)

8 Case presentation History obtained from the patient’s husband revealed no recent infection, fever, weight loss or trauma. History obtained from the patient’s husband revealed no recent infection, fever, weight loss or trauma. She was moving her extremities equally, bilaterally. She was moving her extremities equally, bilaterally. Reflexes were brisk throughout with equivocal plantar response Reflexes were brisk throughout with equivocal plantar response Rest of the neurological exam was limited as the patient was not following commands consistently. Rest of the neurological exam was limited as the patient was not following commands consistently.

9 Case presentations blood pressure was 220/110 mmHg blood pressure was 220/110 mmHg Blood count, routine biochemical tests and ABG were normal Blood count, routine biochemical tests and ABG were normal No ECG abnormalities No ECG abnormalities Chest X-Ray was normal Chest X-Ray was normal

10 D.D. Cerebrovascular accident Cerebrovascular accident Seizures Seizures Complicated migraine Complicated migraine PRES PRES

11 Bilateral regions of edema (hyperintensities in FLAIR and T2-weighted sequences) located in the white matter and predominating in the posterior part of the parietal and occipital lobes. Bilateral regions of edema (hyperintensities in FLAIR and T2-weighted sequences) located in the white matter and predominating in the posterior part of the parietal and occipital lobes. MRI BRAIN

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13 Management Supportive care Supportive care Discontinuation of Tacrolimus Discontinuation of Tacrolimus Nicardipine/labetolol to control BP (rapid BP reduction may aggravate cerebral perfusion and promote ischemia!!!) Nicardipine/labetolol to control BP (rapid BP reduction may aggravate cerebral perfusion and promote ischemia!!!)

14 Outcome Gradual resolution of PRES symptoms Gradual resolution of PRES symptoms Follow-up MRI, 1 mo after discharge, demonstrated normal findings Follow-up MRI, 1 mo after discharge, demonstrated normal findings

15 Conclusions PRES should be considered in the differential diagnosis of patients with a PRES should be considered in the differential diagnosis of patients with a history of bone marrow transplantation history of bone marrow transplantation and/or under tacrolimus-based immunosuppresion. and/or under tacrolimus-based immunosuppresion.

16 Toxic agents in association with PRES Legriel S et al., Annual Update in Intensive Care and Emergency Medicine, 2011

17 Thank you!!! Thank you!!!


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