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 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.
1Michigan 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.
Bhavik
B
Khajuria
Mansi
M
Khajuria
Yashwant
Y
Agrawal
D000328:Adult; D005260:Female; D005921:Glomerulonephritis / Q000188:drug therapy; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects* / Q000627:therapeutic use; D008181:Lupus Nephritis / Q000188:drug therapy*; D009173:Mycophenolic Acid / Q000009:adverse effects* / Q000627:therapeutic use; D054038:Posterior Leukoencephalopathy Syndrome / Q000139:chemically induced* / Q000150:complications / Q000175:diagnosis; D012640:Seizures / Q000150:complications; D012720:Severity of Illness Index
D007166:Immunosuppressive Agents; D009173:Mycophenolic Acid