American Journal of Therapeutics 23, e1072–e1073 (2016)

Mycophenolate-Induced Posterior Reversible Encephalopathy Syndrome Bhavik Khajuria, BSc,1* Mansi Khajuria, BSc,2 and Yashwant Agrawal, MD3

A 29-year-old woman presented with diffuse anasarca and shortness of breath. Workup revealed a creatinine of 3.3 and a glomerular filtration rate of 17. The patient was also found to be pancytopenic with evidence of hemolytic anemia. A renal biopsy showed evidence of stage IV lupus nephritis with rapidly progressive glomerulonephritis. Her lupus was further classified as ANA negative and anti-dsDNA positive. Mycophenolate and triweekly hemodialysis were started along with a steroid burst of methylprednisolone 1 g for 3 days followed by prednisone 60 mg daily. Four days after discharge, the patient represented with a witnessed 3-minute seizure involving bowel incontinence, altered mental status, and tongue biting. She was given 2 mg intravenous lorazepam and loaded with 1000 mg levetiracetam for seizure prophylaxis. Magnetic resonance imaging of the head revealed bilateral posterior hemispheric subcortical edema, and the diagnosis of posterior reversible encephalopathy syndrome was made. Mycophenolate was immediately discontinued and replaced with cyclophosphamide. Strict blood pressure control below 140/90 mm Hg was maintained initially with intravenous nicardipine drip and then transitioned to oral nifedipine, clonidine, losartan, and minoxidil. A repeat head magnetic resonance imaging 8 days later showed resolved subcortical edema consistent with the patient’s improved mental status. No permanent neurologic sequelae were recorded as a result of this hospital episode. Keywords: posterior reversible encephalopathy syndrome, PRES, mycophenolate, mycophenolic acid

INTRODUCTION Posterior reversible encephalopathy syndrome (PRES) is a rare clinical entity associated with malignant hypertension, autoimmune disease, and calcineurin inhibitors. Symptoms include seizure, headache, and altered mental status. The pathophysiology involves subcortical vasogenic edema secondary to hypertension and endothelial damage. As the name suggests, PRES is

1

Michigan State University College of Osteopathic Medicine, East Lansing, MI; 2University of British Columbia, Vancouver, Canada; and 3Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI. The authors have no conflicts of interest to declare. *Address for correspondence: Michigan State University College of Osteopathic Medicine, East Lansing, MI 48824. E-mail: [email protected]

completely reversible with strict blood pressure control, discontinuation of the offending agent, and treating the underlying disease. We report a case of PRES caused by mycophenolate administration.

DISCUSSION Mycophenolate is an immunosuppressive medication commonly used for the treatment of lupus nephritis. The temporal association of PRES with starting and stopping mycophenolate in our patient makes this medication the most likely cause. The patient was also receiving steroids throughout making her autoimmune disease an extremely unlikely cause of PRES. The Naranjo Adverse Drug Reaction Probability Scale rates our association of mycophenolate to PRES as “probable.” To date, there has only been 1 other case report linking mycophenolate to PRES.1 This was in the setting of renal transplantation where

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e1073

Mycophenolate-Induced PRES

mycophenolate was also discontinued resulting in resolution of symptoms.

CONCLUSIONS The clinician must remain vigilant in screening newly initiated medications when presented with PRES. Early diagnosis with head imaging and treatment of blood pressure is crucial to recover and preserve

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neurologic function. Other immunosuppressive medications such as cyclophosphamide may be a better choice in patients with a history of PRES.

REFERENCE 1. Alparslan M, Bora U, Hüseyin K, et al. Posterior reversible encephalopathy syndrome in a renal transplanted patient. Am J Case Rep. 2013;14:241–244.

American Journal of Therapeutics (2016) 23(4)

Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Mycophenolate-Induced Posterior Reversible Encephalopathy Syndrome.

A 29-year-old woman presented with diffuse anasarca and shortness of breath. Workup revealed a creatinine of 3.3 and a glomerular filtration rate of 1...
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