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Severe Tacrolimus Leukoencephalopathy after Liver Transplantation

Janneke Schuuringa, Pieter Wesselingb and Aad Verripsc

a Department of Neurology, University Medical Center Nijmegen, Nijmegen, the Netherlands
b Department of Pathology, University Medical Center Nijmegen, Nijmegen, the Netherlands
c Department of Pediatric Neurology, University Medical Center Nijmegen, Nijmegen, the Netherlands



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  		FIG 1. Radiographic findings in a 12-year-old girl with a severe, reversible tacrolimus-related leukoencephalopathy.

A, Cerebral CT scan shows extensive subcortical hypoattenuation in both parietal regions (canthus-meatus plane, without contrast).

B, T1-weighted MR image obtained in the acute phase (day 1) shows no gadolinium enhancement or decreased signal intensity (5 mm slices, TR 760, TE 15/1, TA 03:42).

C–F, T2-weighted MR images obtained in the acute phase (day 1) show hyperintense lesions in the parietal white matter (C), periventricular white matter (D), cerebellum (E), and brainstem (F) (5 mm slices, TR 3100, TE 98/2, TA 04:03).

G–I, T2-weighted MR images obtained 18 days later (day 19), after a dose reduction of tacrolimus and stereotactic biopsy 6 days earlier, show a remarkable decrease in the hyperintense lesions in the parietal white matter (G). The hyperintense lesions in the cerebellar white matter and brain stem (H) have disappeared. Note the biopsy lesion (I) (5 mm slices, TR 3100, TE 98/2, TA 04:03).

J and K, T2-weighted MR images obtained 5 months after G–I show only a mild right-sided hyperintense lesion (J). In the left hemisphere, the biopsy lesion resides (K) (5 mm slices, TR 3100, TE 98/2, TA 04:03).



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  		FIG 2. Biopsy specimens.

A, In the biopsy fragments, the cerebral white matter shows a normal aspect with ample staining for myelin, absence of inflammatory infiltrate and (in contrast to PML) absence of enlarged nuclei of glial cells. Occasional perivascular macrophages (arrow), however, contain granular, blue-staining material, consistent with myelin debris. (Combined Luxol Fast Blue and Hematoxylin-Eosin staining; original magnification x630).

B, Electron microscopy, performed on material retrieved from the paraffin block, reveals multilamellar particles in the perivascular macrophages, corroborating the myelin nature of these granules.





Copyright © 2009 by the American Society of Neuroradiology. Print ISSN: 0195-6108 Online ISSN: 1936-959X