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CC BY-NC-ND 4.0 · Arq Neuropsiquiatr 2018; 76(10): 720-721
DOI: 10.1590/0004-282X20180093
Images in Neurology

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
Marcos Rosa Júnior
1   Universidade Federal do Espírito Santo, Hospital Universitário Cassiano Antçnio de Moraes, Departamento de Neurorradiologia, Vitória ES, Brasil;
,
Érico Induzzi Borges
2   Universidade Federal do Espírito Santo, Vitória ES, Brasil;
,
Ana Paula Alves Fonseca
2   Universidade Federal do Espírito Santo, Vitória ES, Brasil;
,
Juliana Largura Fiorot
3   Universidade Federal do Espírito Santo, Hospital Universitário Cassiano Antçnio de Moraes, Departamento de Reumatologia, Vitória ES, Brasil.
,
Lídia Balarini
3   Universidade Federal do Espírito Santo, Hospital Universitário Cassiano Antçnio de Moraes, Departamento de Reumatologia, Vitória ES, Brasil.
,
Valéria Valim
3   Universidade Federal do Espírito Santo, Hospital Universitário Cassiano Antçnio de Moraes, Departamento de Reumatologia, Vitória ES, Brasil.
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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]).

Zoom Image
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].


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Conflict of interest:

There is no conflict of interest to declare.

  • 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
  • 2 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
  • 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

Address for correspondence

Marcos Rosa Júnior
Avenida Marechal Campos, 1355, Maruípe; 29043-900 Vitória ES
Brasil   

Publication History

Received: 04 March 2018

Accepted: 16 May 2018

Article published online:
22 August 2023

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  • 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
  • 2 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
  • 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

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Zoom Image
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.