Irreversible Lesions of Tacrolimus-induced Posterior Reversible Leukoencephalopathy Syndrome

Posterior reversible leukoencephalopathy syndrome (PRES) is an acute neurologic dysfunction accompanied by imaging abnormalities of brain which can follow the treatment with calcineurin inhibitors.1 While clinical PRES is mainly reversible when expeditiously recognized, it could be associated with significant morbidity and mortality if diagnosed late.2 A 14-years old boy with end-stage renal disease received a kidney transplant from a deceased donor. He was given polyclonal antibody, for induction, and mycophenolate mofetil, prednisolone, and tacrolimus, as maintenance therapy. Five days after transplantation, he developed headache and seizures. Neurologic examination, vital signs, and other general physical examination were normal. Tacrolimus trough level was within therapeutic range. Lumbar puncture, blood and urine cultures, and other laboratory findings were normal. Echocardiography showed no vegetation. A brain magnetic resonance imaging showed hyperintensity in the subcortical and cortical regions of the bilateral parieto-occipital lobes in T2-weighted, matching PRES. Tacrolimus was replaced by cyclosporine. Seizures were controlled with low-dose antiepileptics. One year after transplantation, the patient had no more episodes of seizure, while the antiepileptic dose was tapered; however, the follow-up imaging showed lesions remained almost unchanged.