Lian Qiaoyan, Wang Lulin, Xu Peihang, Wei Li, Zhou Shouning, Li Xiuhua, Xu Xin, He Jianxing, Ju Chunrong
State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, National Center for Respiratory Medicine, Department of Organ transplantation, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, PR China.
Department of pharmacy, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, 510120, PR China.
Heliyon. 2024 Oct 30;10(21):e39705. doi: 10.1016/j.heliyon.2024.e39705. eCollection 2024 Nov 15.
Tacrolimus is regarded as a cornerstone of immunosuppressive therapy after lung transplantation. Tacrolimus-induced neurotoxicity is common, while late-onset severe encephalopathy is rare.
We report a case of a 61-year-old woman who presented with confusion and limb stiffness 29 months after undergoing bilateral lung transplantation for bronchiectasis. She received immunosuppressive regimen consisting of low-dose tacrolimus, sirolimus, mycophenolate mofetil, and prednisone due to renal insufficiency. Neurological examination revealed gaze deviation towards the right side in both eyes, as well as nuchal rigidity. The muscle strength of her extremities was at grade 1-2, and muscle tone was increased, with a bilateral positive Babinski sign. Blood tests revealed that tacrolimus and sirolimus levels were within the therapeutic range. Brain magnetic resonance imaging revealed that periventricular white matter lesions were slightly more extensive than those observed prior to transplantation. Lumbar puncture showed that cerebrospinal fluid pressure and composition were normal. A diagnosis of tacrolimus-induced encephalopathy was made after a thorough clinical examination. Subsequently, cyclosporine was administered instead of tacrolimus for anti-rejection therapy, and she has remained free of neurological symptoms since then. The improvement of clinical symptoms following the withdrawal of tacrolimus supports the drug-induced etiology of this neurological disorder.
We highlight that tacrolimus-induced encephalopathy can occur in a late stage after lung transplantation and may occur with tacrolimus whole blood concentrations within the therapeutic range.
他克莫司被视为肺移植后免疫抑制治疗的基石。他克莫司引起的神经毒性很常见，而迟发性严重脑病则很少见。
我们报告一例61岁女性，因支气管扩张症接受双侧肺移植29个月后出现意识模糊和肢体僵硬。由于肾功能不全，她接受了由低剂量他克莫司、西罗莫司、霉酚酸酯和泼尼松组成的免疫抑制方案。神经系统检查发现双眼向右凝视偏斜，以及颈项强直。她四肢肌力为1-2级，肌张力增加，双侧巴宾斯基征阳性。血液检查显示他克莫司和西罗莫司水平在治疗范围内。脑磁共振成像显示脑室周围白质病变比移植前观察到的略广泛。腰椎穿刺显示脑脊液压力和成分正常。经过全面的临床检查后诊断为他克莫司诱发的脑病。随后，改用环孢素代替他克莫司进行抗排斥治疗，此后她一直没有神经症状。停用他克莫司后临床症状改善支持了这种神经疾病的药物诱发病因。
我们强调他克莫司诱发的脑病可发生在肺移植后期，且可能在他克莫司全血浓度在治疗范围内时发生。
