A case of tacrolimus-induced reversible cerebral vasoconstriction syndrome after heart transplantation

Reversible cerebral vasoconstriction syndrome (RCVS) after heart transplantation is a rare, but serious complication, because of a high risk for permanent neurological deficits or allograft rejection. A 48-year-old female who underwent orthotropic heart transplantation presented with a sudden severe headache 10 days after transplantation. Although magnetic resonance angiography (MRA) findings at initial symptom onset were normal, MRA finding at the next day revealed multifocal vasoconstriction of cerebral arteries. Tacrolimus-induced RCVS was strongly suspected, and tacrolimus was immediately discontinued and basiliximab was added as an alternative immunosuppressant. Notably, neurological symptoms occurred at the time of sharp increase in serum tacrolimus levels and resolved when it decreased to low levels. Follow-up MRA showed complete remission and she recovered without any neurological symptom or allograft rejection. Our case suggests that prompt diagnosis with repeated MRA and immediate discontinuation of tacrolimus are essential to avoid severe neurological sequelae of RCVS.