Tacrolimus-Associated Psychotic Disorder: A Report of 2 Cases.

Psychotic disorders are a group of psychiatric disorders characterized by the presence of delusions, hallucinations, bizarre behavior, and disorganized speech. There are several possible causes for the occurrence of psychotic disorders in patients who underwent solid organ transplant, including pre-existing mental illness, electrolyte disturbances, infections of the central nervous system, and adverse reaction to drugs. Calcineurin inhibitors are a class of immunosuppressive drugs, such as tacrolimus and cyclosporine, that are currently considered the mainstay in the immunosuppressive drug regimen of patients who underwent solid organ transplant. Neurotoxicity is one of the adverse reactions associated with the use of calcineurin inhibitors, ranging from upper limb tremors to psychotic disorders and seizures. We report the cases of 2 liver transplant recipients who developed severe psychotic disorder 1 month after the procedure. After an extensive investigation for other possible triggers of psychiatric disease, the use of tacrolimus was considered to be the most likely cause for the acute psychotic disorder. In less than 24 hours after suspension of that drug, all symptoms disappeared in both patients, making a causal relationship with tacrolimus even more likely. The patients were then given cyclosporine, another drug from the same class, allowing for adequate immunosuppression and preserved graft function, with no further psychiatric symptoms. This report confirms that a 24-hour trial of tacrolimus suspension can be safe and effective in the diagnosis of drug-related psychotic disorders in patients who underwent liver transplant. This article is compliant with the Helsinki Congress and the Istanbul Declaration.

Visceral Leishmaniasis in a Liver Transplant Patient: A Case Report.

Leishmaniasis is an infection caused by protozoa of the genus Leishmania, transmitted by sandflies and endemic to more than 88 countries. Visceral leishmaniasis in immunosuppressed patients is a growing concern. We report the case of a 61-year-old male patient with a previous history of alcoholic cirrhosis and portal vein thrombosis who underwent liver transplantation for the treatment of hepatocellular carcinoma. Thirty-six days after the procedure, the patient showed an increase in liver enzymes and was diagnosed with moderate acute rejection of the graft. He was treated with high-dose intravenous corticosteroids, and while showing improvement in biochemical markers, he became febrile 12 days after corticosteroid treatment. He presented daily episodes of fever, even after the use of several antimicrobial, antiviral, and antifungal agents, and a number of negative cultures from different sites were obtained. A bone marrow biopsy was then performed, showing a large number of amastigote forms of Leishmania spp. Treatment with liposomal amphotericin B was initiated; however, the patient progressed to refractory septic shock and death. This case highlights several aspects of visceral leishmaniasis in liver transplant recipients, such as the association of malnutrition to Leishmania infection and the challenges of diagnosing leishmaniasis in cirrhotic patients in which splenomegaly and pancytopenia, the hallmarks of leishmaniasis, may also be attributed to portal hypertension and end-stage liver disease. A high index of suspicion is necessary for the correct diagnosis and treatment of leishmaniasis in this group of patients. This study is compliant with the Helsinki Congress and the Istanbul Declaration.

Extensive Inferior Vena Cava Thrombosis in a Liver Transplant Patient: A Case Report.

Thrombosis of the inferior vena cava is a clinical condition with very diverse presentations, ranging from asymptomatic patients to others with severe edema in the legs and lower torso. We report the case of a 27-year-old female patient, previously diagnosed with autoimmune hepatitis, with asymptomatic extensive thrombosis of the inferior vena cava. The thrombus extended from the renal veins up to the emergence of the hepatic veins, causing post-sinusoidal portal hypertension (Budd-Chiari syndrome). The patient underwent an orthotopic cadaveric liver transplant with removal of the retrohepatic vena cava and thrombectomy of blood clots from the infrahepatic vena cava. She initially recovered well from surgery, but on the 8 postoperative day she had a significant increase in hepatic injury markers and was diagnosed with rethrombosis of the inferior vena cava and hepatic veins. A surgical thrombectomy was performed, with an intraoperative finding of chronic thrombus in both renal veins, previously undiagnosed. The thrombectomy was successful, but the patient's hepatic function continued to worsen and a second liver transplant was performed. After the second transplant she underwent several imaging exams that showed no signs of rethrombosis. She was kept on postoperative anticoagulation indefinitely, first with intravenous heparin then with rivaroxaban. An extensive investigation failed to identify any causes of thrombophilia associated with this vast thrombosis. She is currently alive and with good graft function 1 year and 4 months after the second transplant.