PRES Induced by Cyclosporin with Normal Blood Concentrations in a Bone Marrow Recipient

Abstract

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinic neuroradiological entity. This syndrome occurs in complex conditions as allogenic bone marrow transplantation, organ transplantation and immunosuppressant therapy such as cyclosporin (CsA). The occurrence of PRES is favored by a high concentration of CsA. Therefore, therapeutic monitoring of CsA is necessary to effects due to overdose. The therapeutic range of CsA is between 150-300 ng/mL. We aimed to present a case PRES induced by CsA in bone marrow transplantation with normal cyclosporine blood concentrations. Case: A 26 years old man received an allogenic bone marrow for bone marrow aplasia in January 2013. He was treated by CsA. Mean CsA dose was 2.57 mg/kg/day. CsA mean blood concentration was 295 ng/mL. After 20 days, our patient presented a complex partial seizure and cortical abnormal. He had no history of head injury, epilepsy or hypertension and there was no family history of neurological or psychiatric disorders. Patient’s blood pressure wasn’t measured. CsA was stopped. He received mycophenolate acid and clonazepam. Seizure and abnormal vision vanished 10 days later. Whereas, the patient developed graft-versus-host disease (GVHD). Then, mycophenolate acid was stopped 1.5 month later and CsA taken back. CsA mean dose was 1.1 mg/kg/day. Mean CsA blood concentration was 167.71 ng/mL. After two months, the patient developed general seizures and in Magnetic Resonance Imaging (MRI) there was a low-density in the subcortical white matter areas. So, CsA was stopped once and for all and the seizures vanished few days later. Conclusion: PRES is responsible for various and no specific neurological symptoms. These symptoms are usually reversible but sometimes fatal. Therapeutic monitoring of CsA was necessary to avoid neurotoxicity depending of concentration but we must remain cautious even if patients have CsA blood concentrations in the therapeutic range.