Tacrolimus-induced neurotoxicity from bipolar disorder to status epilepticus under the therapeutic serum level: a case report

Abstract Background Tacrolimus is a macrolide immunosuppressant widely used to prevent rejection after solid organ transplantation. In general, adverse events of tacrolimus occur more often as the concentration of tacrolimus in the blood increases. We report the case of a 39-year-old man who developed a variety of adverse events despite in the therapeutic level of tacrolimus in the blood. Case presentation A 39-year-old man underwent liver transplantation for liver cirrhosis due to alcoholic liver disease. The postoperative immunosuppressant consisted of tacrolimus (5 mg) and mycophenolate (500 mg) twice daily. Five months after taking tacrolimus, he presented with talkativeness, which gradually worsened. Brain magnetic resonance imaging performed 10 months after tacrolimus administration revealed a hyperintense lesion affecting the middle of the pontine tegmentum on T2WI. The blood concentration of tacrolimus was 7.2 ng/mL (therapeutic range 5–20 ng/mL). After 21 months, he exhibited postural tremor in both the hands. Twenty-four months after taking tacrolimus, he showed drowsy mentality, intention tremor, and dysdiadochokinesia. Electroencephalography presented generalized high-voltage rhythmic delta waves; therefore, tacrolimus was discontinued in suspicion of tacrolimus-induced neurotoxicity, and anticonvulsive treatment was started. The level of consciousness gradually improved, and the patient was able to walk independently with mild ataxia. Conclusion This case shows that tacrolimus-induced neurotoxicity can occur even at normal concentrations. Therefore, if a patient taking tacrolimus exhibits psychiatric or neurologic symptoms, neurotoxicity should be considered even when the blood tacrolimus is within the therapeutic range.

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Unusual presentation of acute encephalopathy with biphasic seizures and late reduced diffusion in Miller–Dieker syndrome

10.21203/rs.2.9548/v1 ◽

2019 ◽

Author(s):

Satoru Kobayashi ◽

Mai Kamishima ◽

Akari Tago ◽

Kyoko Yokoi ◽

Satoshi Suzuki

Keyword(s):

Brain Magnetic Resonance Imaging ◽

Subcortical White Matter ◽

Acute Encephalopathy ◽

Case Presentation ◽

Delta Waves ◽

Diffusion Weighted Images ◽

Disturbance Of Consciousness ◽

Intravenous Diazepam ◽

Severe Motor ◽

Magnetic Resonance Imaging Mri

Abstract Background: Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) is a unique subtype of acute encephalopathy that occurs in children. To date, there is no description of a patient with concurrent Miller–Dieker syndrome (MDS) and AESD. Case presentation: We present a case of 2-year-old girl with MDS, who was admitted for status epilepticus with a high fever, was diagnosed with AESD. She exhibited seizure for more than 1 h, which disappeared after administration of intravenous diazepam and phenobarbital. Brain magnetic resonance imaging (MRI), performed on the third day post-admission because she had not regained consciousness after the seizure ceased, showed abnormally high intensities in subcortical white matter, predominantly in the frontal areas on diffusion-weighted images (DWI). Acute encephalitis/encephalopathy was diagnosed based on electroencephalography (EEG) findings of diffuse high-voltage delta waves without seizure activity. Six days post-admission, frequent apneic episodes were observed, with oxygen desaturation due to clustered seizures. Although seizures disappeared with continuous intravenous midazolam, subclinical seizures were present in amplitude-integrated EEG (aEEG); these were suppressed by increasing the midazolam dose. Conclusion: This is the first report of AESD in a patient with MDS. Ther disturbance of consciousness was difficult to recognize because of severe motor and intellectual disabilities due to MDS. EEG aids the evaluation of consciousness in the acute phase, and aEEG can be helpful for monitoring and controlling subclinical seizures in the biphasic phase of AESD, especially patients with underlying neurological disorders.

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CEFEPIME-INDUCED COTARD SYNDROME: A CASE REPORT

10.7244/cmj.2021.01.001 ◽

2021 ◽

Author(s):

Molly Howland ◽

Chelsea Markle ◽

Jennifer Erickson ◽

Thomas Soeprono

Keyword(s):

Low Dose ◽

Solid Organ Transplantation ◽

Severe Depression ◽

Solid Organ ◽

Visual Hallucinations ◽

Past Medical History ◽

Case Presentation ◽

Mri Brain ◽

History Of ◽

Acute Changes

Background: Cotard syndrome features nihilistic delusions about one’s body or existence and is typically related to severe depression though is rarely associated with medical or neurological insults. Case presentation: The patient was a 62-year-old male with no past psychiatric history and a past medical history of congestive heart failure and consequent renal failure who presented for scheduled heart and kidney transplantation. He was started on routine post-transplant ganciclovir and steroids. Due to postoperative hypotension, empiric cefepime was initiated to cover for septic shock. One week postoperatively, the patient stated “I am dead.” He elaborated that “an intern overdilated me” during transplantation and declined tacrolimus. The patient also reported visual hallucinations of green algae and bubbles. He denied depression and was attentive and oriented. He had a Bush-Francis score of 9. MRI brain revealed no acute changes. Low-dose haloperidol was initiated for psychosis. Cefepime was discontinued, but ganciclovir and steroids were continued. Two days later, the symptoms fully resolved. Discussion: This is the first reported case of Cotard syndrome as an acute transplant complication. Though corticosteroid-induced psychosis was initially suspected, cefepime neurotoxicity is the more likely explanation given the correlation between the antibiotic and symptom courses. Older age and renal dysfunction were risk factors. Conclusions: Cotard Syndrome can be an acute complication of solid organ transplantation, where renal impairment and polypharmacy are common. Transplantation teams and consult-liaison psychiatrists should work together to manage this syndrome.

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An unusual Neuronal Intranuclear Inclusion Disease with Chief Complaint of Autonomic Dysfunction

10.21203/rs.2.1814/v2 ◽

2019 ◽

Author(s):

Xiaoyun Liu ◽

Xiaohui Liu ◽

Yifeng Du ◽

Chunxia Li ◽

Cuicui liu ◽

...

Keyword(s):

Brain Magnetic Resonance Imaging ◽

Intranuclear Inclusions ◽

Resonance Imaging ◽

Dominant Group ◽

Intranuclear Inclusion ◽

Case Presentation ◽

Level Of Consciousness ◽

Recurrent Vomiting ◽

Neuronal Intranuclear Inclusion ◽

Magnetic Resonance Imaging Mri

Abstract Background Neuronal intranuclear inclusion disease (NIID) is a recently defined disease entity of progressive neurodegenerative disease with characterizations of eosinophilic hyaline intranuclear inclusions in neuronal and somatic cells. The sporadic adult-onset NIID cases were previous described as ‘dementia dominant group’. Here we present a NIID case manifested prominently with recurrent vomiting. Case presentation A 60-year-old women present with paroxysmal vomiting, hypertention and decreased level of consciousness for 3 years. She was diagnosed with NIID based on history, clinical features, brain magnetic resonance imaging(MRI), skin biopsy. Conclusion Autonomic symptoms may manifest as the initial and predominant presentation of NIID. This case presentation may extend the spectrum of NIID and may give new insights in exploring the pathogenic mechanisms of NIID.

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Enteric-Coated Mycophenolate Sodium

Annals of Pharmacotherapy ◽

10.1345/aph.1d063 ◽

2003 ◽

Vol 37 (11) ◽

pp. 1685-1693 ◽

Cited By ~ 34

Author(s):

Steven Gabardi ◽

Jennifer L Tran ◽

Michael R Clarkson

Keyword(s):

Mycophenolate Mofetil ◽

Adverse Events ◽

Acute Rejection ◽

Mycophenolic Acid ◽

Solid Organ Transplantation ◽

Solid Organ ◽

Renal Transplant Recipients ◽

Efficacy And Safety ◽

Mycophenolate Sodium ◽

Enteric Coated

OBJECTIVE: To review the pharmacology, pharmacokinetics, efficacy, and safety of mycophenolate sodium. DATA SOURCES: Primary literature was obtained via a MEDLINE search (1966–June 2003). Abstracts were obtained from the manufacturer and included in the analysis. STUDY SELECTION AND DATA EXTRACTION: All studies and abstracts evaluating mycophenolate sodium in solid organ transplantation were considered for inclusion. English-language studies and abstracts were selected for inclusion, but were limited to those consisting of human subjects. DATA SYNTHESIS: Mycophenolate sodium, a mycophenolic acid prodrug, is an inhibitor of T-lymphocyte proliferation. Mycophenolic acid reduces the incidence of acute rejection in renal transplantation. Mycophenolate sodium is enteric coated and has been suggested as a potential method to reduce the gastrointestinal adverse events seen with mycophenolate mofetil. Both mycophenolate mofetil and mycophenolate sodium have been shown to be therapeutically equivalent at decreasing the incidence of allograft rejection and loss. The frequency of adverse events is similar between both compounds, with the most common events being diarrhea and leukopenia. CONCLUSIONS: Mycophenolate sodium is effective in preventing acute rejection in renal transplant recipients. At doses of 720 mg twice daily, the efficacy and safety profiles are similar to those of mycophenolate mofetil 1000 mg twice daily. Mycophenolate sodium has been approved in Switzerland; approval in the US is pending.

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A Case report of Recurrent Vomiting: Extending the Spectrum of Neuronal Intranuclear Inclusion Disease

10.21203/rs.2.1814/v1 ◽

2019 ◽

Author(s):

Xiaoyun Liu ◽

Xiaohui Liu ◽

Yifeng Du ◽

Chunxia Li ◽

Cuicui liu ◽

...

Keyword(s):

Brain Magnetic Resonance Imaging ◽

Intranuclear Inclusions ◽

Resonance Imaging ◽

Dominant Group ◽

Intranuclear Inclusion ◽

Case Presentation ◽

Level Of Consciousness ◽

Recurrent Vomiting ◽

Neuronal Intranuclear Inclusion ◽

Magnetic Resonance Imaging Mri

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Identifying Patterns of Adverse Events of Solid Organ Transplantation Through Departmental Case Reviews

Mayo Clinic Proceedings Innovations Quality & Outcomes ◽

10.1016/j.mayocpiqo.2019.04.007 ◽

2019 ◽

Vol 3 (3) ◽

pp. 335-343 ◽

Cited By ~ 2

Author(s):

Amit K. Mathur ◽

Cynthia Stemper-Bartkus ◽

Kevin Engholdt ◽

Andrea Thorp ◽

Melissa Dosmann ◽

...

Keyword(s):

Adverse Events ◽

Organ Transplantation ◽

Solid Organ Transplantation ◽

Solid Organ

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Treatment-emergent adverse events after infusion of adherent stem cells: the MiSOT-I score for solid organ transplantation

Trials ◽

10.1186/1745-6215-13-211 ◽

2012 ◽

Vol 13 (1) ◽

Cited By ~ 10

Author(s):

Johannes Dillmann ◽

Felix C Popp ◽

Barbara Fillenberg ◽

Florian Zeman ◽

Elke Eggenhofer ◽

...

Keyword(s):

Stem Cells ◽

Adverse Events ◽

Organ Transplantation ◽

Solid Organ Transplantation ◽

Solid Organ

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Lethal thrombosis of the iliac artery caused by Aspergillus fumigatus after liver transplantation: case report and review of the literature

BMC Surgery ◽

10.1186/s12893-019-0668-4 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 2

Author(s):

Jan-Paul Gundlach ◽

Rainer Günther ◽

Helmut Fickenscher ◽

Marcus Both ◽

Christoph Röcken ◽

...

Keyword(s):

Liver Transplantation ◽

Aspergillus Fumigatus ◽

Iliac Artery ◽

Histopathological Examination ◽

Solid Organ Transplantation ◽

Solid Organ ◽

Review Of The Literature ◽

Case Presentation ◽

Artery Thrombosis ◽

The Brain

Abstract Background Aspergillus fumigatus infections frequently occur after solid organ transplantation. Yet, a fungal thrombosis after liver transplantation is an exceptional finding. Case presentation We report on a 44-year-old female with an aspergillosis after liver transplantation for autoimmune hepatitis. On postoperative day (pod) 7, seizures occurred and imaging diagnostics revealed an intracranial lesion. Anidulafungin was initiated in suspicion of mycosis and switched to voriconazole on suspicion of an Aspergillus spp. infection. Progression of the cerebral lesion prompted craniotomy (pod 48) and the aspergillosis was verified. The patient was discharged with oral voriconazole therapy. Re-admission was necessary with acute-on-chronic renal failure after a tacrolimus overdose on pod 130. The patient received a pelvic angiography due to a temperature difference in the legs. It showed a complete iliac artery thrombosis which was subsecutively surgically removed. The histopathological examination revealed an Aspergillus fumigatus conglomerate. The patient died on pod 210 due to systemic aspergillosis. Conclusion The acute development of focal neurologic deficits is common in patients with an aspergillosis of the brain. Nevertheless, arterial thrombosis after Aspergillus fumigatus is less frequent and, to the best of our knowledge, its occurrence after liver transplantation has not yet been reported so far. Due to its rarity, we added a review of the literature to this manuscript.

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