Fatal PRES and super-refractory status epilepticus after combined heart and kidney transplant: A case report and literature review

Prevention of acute allograft dysfunction is the principal focus in the immediate post-transplant period. However, many immune-modulating agents have been associated with posterior reversible encephalopathy syndrome (PRES). We describe a complex case of extended critical illness triggered by PRES in the immediate post-transplant period, leading to super-refractory status epilepticus of unclear etiology and acute rejection of the 2 transplanted organs. Brain autopsy showed findings of multifocal necrotizing leukoencephalopathy (MNL). Our patient differed from previously described cases of PRES after heart transplantation in that our patient did not receive calcineurin inhibitors and had a fatal outcome. A delicate balance must be maintained between the risk of acute rejection in a high-risk patient with inadequate immunosuppression vs the risk of PRES from the use of aggressive immunosuppression. Furthermore, several antiseizure medications interfere with the metabolism of immunosuppressive medications and these potential interactions must be carefully considered to reduce morbidity and prevent mortality. Lastly, our case suggests that perhaps MNL should be considered in the differential diagnosis for refractory seizures in the setting of established risk factors, such as immunosuppression and sepsis.