Tacrolimus-Related Neurotoxicity of the Pons in Children: Review of the Literature and a Case Report.

Introduction: Tacrolimus is a potent immunosuppressive agent effective in preventing solid organ transplant rejection. It is widely used following allogeneic liver, kidney, heart, and bone marrow transplantation. Tacrolimus-related neurotoxicity, which can present in up to one-third of patients, manifests with a broad clinical spectrum. Neuroradiological features are classically reported as bilateral and symmetrical lesions involving the parietal and occipital lobes, similar to posterior reversible encephalopathy syndrome. Tacrolimus-related toxicity can also affect other parts of the brain, including the brainstem, although isolated brainstem involvement is rare. Methods: This report describes a patient who had tacrolimus-related neurotoxicity with an isolated brainstem lesion in which symptoms resolved with only a brief hold of the tacrolimus. A literature review identified four other pediatric patients who had tacrolimus-associated neurotoxicity with isolated brainstem involvement. Discussion: Tacrolimus-associated neurotoxicity with pontine lesions in children is rare. In previously reported patients, tacrolimus was discontinued and neurological symptoms resolved. Our patient developed tacrolimus-associated clinical changes and pontine lesions that improved following a brief hold of the tacrolimus treatment. This girl highlights tacrolimus-associated neurotoxicity isolated to the brainstem in pediatric patients and demonstrates that tacrolimus may be safely restarted with careful monitoring and follow-up.