Posterior reversible encephalopathy syndrome during treatment with tocilizumab in juvenile idiopathic arthritis

Síndrome da encefalopatia posterior reversível após tratamento com tocilizumab em paciente com artrite idiopática juvenil

A 17-year-old man with normal blood pressure presented with acute bilateral blindness, and retro-orbital pain two days after treatment with tocilizumab (TCZ) for juvenile idiopathic arthritis. The diagnosis was posterior reversible encephalopathy syndrome (PRES), made after clinical examination and MRI (Figure).

Figure
MRI showed cortical and subcortical FLAIR hyperintense signals involving the occipital lobes (A), with restricted diffusion (B) and contrast enhancement (C). The findings of diffusion restriction and contrast enhancement are more severe imaging findings and are described as factors of a worse prognosis and partial recovery in PRES. After TCZ withdrawal, the patient's imaging findings improved (D, E, and F), with partial recovery of the visual symptoms.

Tocilizumab was discontinued and the patient partially improved. To the best of our knowledge, there are no reports of this association (PRES and TCZ) in PubMed. This manuscript describes a new association between TCZ and PRES based on imaging findings, in which the patient presented with more severe imaging findings and did not have complete recovery of the symptoms^1,2,3.

References

• ¹
  Yokota S, Tanaka T, Kishimoto T. Efficacy, safety and tolerability of tocilizumab in patients with systemic juvenile idiopathic arthritis. Ther Adv Musculoskelet Dis. 2012;4(6):387-397. https://doi.org/10.1177/1759720X12455960
  » https://doi.org/10.1177/1759720X12455960
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  Dueckers G, Guellac N, Arbogast M, Dannecker G, Foeldvari I, Frosch M et al. Evidence and consensus based GKJR guidelines for the treatment of juvenile idiopathic arthritis. Clin Immunol. 2012;142(2):176-193. https://doi.org/10.1016/j.clim.2011.10.003
  » https://doi.org/10.1016/j.clim.2011.10.003
• ³
  Hinchey J, Chaves C, Appignani B, Breen J, Pao L, Wang A et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(8):494-500. https://doi.org/10.1056/NEJM199602223340803
  » https://doi.org/10.1056/NEJM199602223340803

Publication Dates

• Publication in this collection
  Oct 2018

History

• Received
  04 Mar 2018
• Reviewed
  14 May 2018
• Accepted
  16 May 2018