Abstract Details

Title Tacrolimus Induced Osmotic Demyelination in Patient with Liver Transplantation

Topic General Neurology

Presentation(s) P5 - Poster Session 5 (5:30 PM-6:30 PM)

Poster/Presentation
Number 7-027

Objective We describe a patient with Budd Chiari syndrome who underwent a deceased donor liver transplantation and immunosuppression treatment with tacrolimus who developed Tacrolimus induced ODS greater than one year after initiation of therapy.

Background Osmotic Demyelination syndrome (ODS) has been associated with rapid correction of hyponatremia. This syndrome is characterized by demyelination due to loss of osmotically active organic molecules from supporting glial cells resulting in edema. There are few reports of immunosuppressive agents causing osmotic demyelination, and little is known about the timing and pathogenesis of this complication.

Design/Methods Case report

Results A 27 year-old right handed African American man with Budd Chiari syndrome underwent a liver transplantation and received immunosuppression with tacrolimus. He presented to our ER 15 months later with acute left temporal headache, right upper and lower extremity weakness and slurred speech. His neurologic examination demonstrated normal mentation, right facial droop, right upper and lower extremity weakness, diffuse hyperreflexia including bilateral ankle clonus. Brain MRI showed diffuse and patchy T2/FLAIR hyperintensities, Diffusion restriction, decreased signal on ADC mapping, as well as T1 post contrast enhancement in the pons, cerebral peduncles, and cerebellar peduncles bilaterally. Notably, tacrolimus levels were within therapeutic range. Patient underwent extensive infectious and malignancy workup including SPECT, PET and CT scans, lumbar puncture and cytology which were all negative.

Conclusions This is a unique case highlighting the development of Tacrolimus ODS in a patient post liver transplantation. Demyelination, endothelial damage and cytotoxic edema after prolonged drug exposure are proposed mechanisms of tacrolimus induced neurotoxicity. After discontinuation and substitution of tacrolimus with cyclosporine, significant resolution of his lesions were seen on follow up MRI. Identification of tacrolimus as a potential offender of ODS and its timely cessation is important, as the disease process can be limited and improved as noted in this case.

Authors/Disclosures
Juan Pablo Pauta Martinez, MD PRESENTER	Dr. Pauta Martinez has nothing to disclose.
John P. Holton-Burke, MD (Rochester regional health)	No disclosure on file
Prachi Mehndiratta, MD	Dr. Mehndiratta has nothing to disclose.

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