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Central pontine myelinolysis: a case report and clinical-pathological review
Rosa Cui1, Sameh Fayek, Elizabeth B Rand
1Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. Rosa.Cui@uphs.upenn.edu
Insights
Pediatric liver transplant patients experiencing neurotoxicity, such as central pontine and extrapontine myelinolysis, may benefit from switching from calcineurin inhibitors (CNIs) like tacrolimus to rapamycin for improved neurological recovery.
Area of Science:
- Neuroscience
- Transplantation Medicine
- Pediatric Neurology
Background:
- Calcineurin inhibitors (CNIs) like tacrolimus are standard immunosuppressants post-liver transplant.
- Neurotoxicity is a known, albeit less common, complication associated with CNI use.
- Early identification of neurological symptoms is crucial for timely intervention.
Observation:
- An 11-year-old presented with acute mental status changes and spastic quadriplegia post-liver transplant.
- MR imaging revealed central pontine and extrapontine myelinolysis (EPM).
- The patient was initially on tacrolimus, mycophenolate mofetil, and corticosteroids.
Findings:
- The patient's neurological symptoms improved significantly after switching from tacrolimus to rapamycin.
- This suggests a direct link between CNI-related neurotoxicity and the observed symptoms.
- Rapamycin served as a successful alternative immunosuppressant.
Implications:
- Prompt recognition and management of CNI-induced neurotoxicity are vital in pediatric transplant recipients.
- Switching to an alternative immunosuppressant, such as rapamycin, can lead to substantial neurological recovery.
- This case highlights the importance of considering drug-induced neurotoxicity in post-transplant patients with new neurological deficits.
Abstract:
An 11-yr-old child presented with acute mental status changes and spastic quadriplegia after orthotopic liver transplantation. Magnetic resonance (MR) imaging findings were consistent with central pontine and EPM. Initial immunosuppression included tacrolimus, mycophenolate mofetil, and corticosteroids. Given that neurotoxicity is a well-established side effect of CNI, the patient was converted to rapamycin and subsequently experienced significant neurologic recovery. The temporal resolution of the patient's symptoms suggests that prompt recognition of central pontine and EPM and conversion from tacrolimus to rapamycin during the early post-operative course may have therapeutic benefits for patients undergoing pediatric transplant with CNI-related neurotoxicity.
