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Published on: November 8, 2015
Tacrolimus Induced Thrombotic Microangiopathy (TMA) Presenting as Acute Macular Neuroretinopathy
Ashish Markan1, Nikitha Ayyadurai1, Ramandeep Singh1
1Advanced Eye Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Abstract:
This report highlights the association of tacrolimus use with acute macular neuroretinopathy (AMN). A 27-year-old woman, a known case of diffuse proliferative membranous glomerulonephritis, developed abnormal body movements, loss of consciousness, and blurring of vision in the left eye, after 3 months of starting tacrolimus. Blood investigations revealed anemia, thrombocytopenia, raised urea and creatinine levels, and raised LDH levels. A diagnosis of tacrolimus induced hemolytic uremic syndrome (HUS) with posterior reversible encephalopathy syndrome (PRES) was made. Ocular examination revealed a reddish-brown petaloid retinal lesion, which was better appreciated on red-free imaging as dark grey area pointing towards the fovea. OCT-A and SD-OCT revealed flow voids in deep retinal plexus, and disruption of ellipsoid and interdigitation zone, respectively, findings consistent with AMN. To the best of our knowledge, it is the first report of association of tacrolimus with AMN.
Insights
This case report details a rare association between tacrolimus medication and acute macular neuroretinopathy (AMN). The patient developed AMN alongside tacrolimus-induced hemolytic uremic syndrome (HUS) and posterior reversible encephalopathy syndrome (PRES).
Area of Science:
- Ophthalmology
- Nephrology
- Neurology
Background:
- Tacrolimus is an immunosuppressant commonly used in organ transplantation and autoimmune diseases.
- Diffuse proliferative membranous glomerulonephritis is a serious kidney condition.
- Hemolytic uremic syndrome (HUS) and posterior reversible encephalopathy syndrome (PRES) are known potential side effects of tacrolimus.
Observation:
- A 27-year-old woman with glomerulonephritis presented with neurological symptoms and vision loss after 3 months of tacrolimus therapy.
- Blood tests indicated anemia, thrombocytopenia, and elevated kidney and LDH levels, consistent with HUS and PRES.
- Ocular examination revealed characteristic petaloid retinal lesions and foveal involvement.
Findings:
- Optical Coherence Tomography Angiography (OCT-A) showed flow voids in the deep retinal plexus.
- Spectral Domain Optical Coherence Tomography (SD-OCT) revealed disruption of the ellipsoid and interdigitation zones.
- These findings confirmed the diagnosis of acute macular neuroretinopathy (AMN) in the affected eye.
Implications:
- This is the first reported case linking tacrolimus use to acute macular neuroretinopathy (AMN).
- Highlights the importance of ophthalmological examination in patients experiencing visual disturbances while on tacrolimus.
- Suggests a potential mechanism for tacrolimus-induced retinal toxicity that warrants further investigation.
