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

Abstract 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.