ABC Heart Fail Cardiomyop 2023; 3(4): e20240005
Tacrolimus-Associated Posterior Reversible Encephalopathy Syndrome after Heart Transplantation
Gabriel Gomes de Sousa
, José Erirtônio Façanha Barreto Júnior, Rivania Beatriz Novais Lima Pimentel
, Thiago Antônio Pessoa Carneiro, Jefferson Luís Vieira
The posterior reversible encephalopathy syndrome (PRES) is an uncommon neurotoxicity known to occur following solid organ transplantation, potentially associated with cyclosporine and tacrolimus.1,2 It was originally described by Hinchey et al. in 1996 as a reversible syndrome characterized by headache, altered mental function, seizures, and visual disturbances,3 and represents a clinical and neuroradiological entity with typical neurological deficits, distinctive magnetic resonance imaging (MRI) features, and a benign clinical course. Herein, we present the case of a 39-year-old man with a medical history of idiopathic cardiomyopathy who developed severe headache, visual disturbances, and altered mentation 20 days after orthotopic heart transplantation while awaiting predischarge routine surveillance endomyocardial biopsy (EMB) in the hospital. His immunosuppressive therapy included 7 mg of tacrolimus, 720 mg of sodium mycophenolate, 20 mg of prednisone, and valganciclovir. Upon neurological examination, he exhibited no focal deficits, with a blood pressure of 120/80 mmHg and a pulse of 100 beats/min. Laboratory findings were unremarkable, with tacrolimus levels of 9.2 ng/mL, consistent with his stable previous levels. Initially managed with diazepam and intravenous phenytoin, a brain MRI revealed findings suggestive of PRES, including vasogenic edema evident in the occipital and temporo-occipital junction.
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