(190) A curious case of psychosis post-liver transplant

Abstract: Background

Most cases of post-transplantation psychosis described in the literature are associated with immunosuppressants use in patients with prior psychiatric disorder. This case report will expand on the differential diagnosis of post-transplantation psychosis in a patient without prior psychiatric history.

Case

A 66-year-old woman with no past substance abuse or other psychiatric history, was diagnosed with non-alcoholic steatohepatitis and hepatocellular carcinoma. She underwent an orthotopic liver transplant (OLT) and was discharged 10 days later, after an unremarkable post-surgical course. She was readmitted 7 weeks later due to ischemic cholangiopathy. She had non-specific symptoms such as “communication impairment”, anxiety, depression and “compulsions”.

The consulting liaison psychiatry team concluded: new onset psychosis with cognitive difficulties. Although her family psychiatric history was significant for bipolar type 1 and substance use disorders, the initial differential diagnosis included delirium, psychosis secondary to corticosteroids and posterior reversible encephalopathy syndrome (PRES). Blood tests, EEG and MRI were unremarkable. A lumbar puncture revealed positive herpes simplex virus type 1 (HSV-1) PCR in CSF. With acyclovir and olanzapine 20 mg/day, her cognition improved but suspiciousness and other psychotic symptoms persisted. Modification of calcineurin inhibitors was attempted despite normal tacrolimus level but did not lead to further improvement.

Discussion

Our case is interesting due to the finding of HSV-1 encephalitis, a rare complication in post-transplant, as well residual psychosis despite appropriate treatment with acyclovir. In our patient, prior significant family history of bipolar disorder raised concern about a primary psychiatric disorder. The continued cognitive and psychotic symptoms elicited a broader differential diagnosis, which includes delirium, hepatic encephalopathy, and a side effect of corticosteroids and calcineurin inhibitors. Neuropsychiatric symptoms are reported in up to 5% of patients taking calcineurin inhibitors, with psychosis noted as a rare complication (most often occurring with supratherapeutic levels) (Bechstein, 2000). Another complication of calcineurin inhibitors is PRES, which can present with hallucinations, agitation and altered mental state (Apuri, 2014). Our case also exemplifies that encephalitis should be considered when encountering an atypical psychotic disorder with prominent cognitive symptoms.

Conclusion

In summary, our case illustrates diagnostic and therapeutic challenges in atypical presentation of psychosis post-liver transplant. It reflects the likelihood of neurocognitive repercussions of medications used in transplant and of further neurological complications. Since optimal treatment of psychosis is necessary to achieve best outcomes regarding adherence with care, multidisciplinary involvement is key to address these challenging issues. Further studies are required to better understand how to optimally investigate and manage post-transplant psychosis.

References

- Apuri S, Carlin K, Bass E, Nguyen PT, Greene JN. Tacrolimus associated posterior reversible encephalopathy syndrome - a case series and review. Mediterr J Hematol Infect Dis. 2014;6(1):e2014014.
- Bechstein WO. Neurotoxicity of calcineurin inhibitors: impact and clinical management. Transpl Int. 2000;13(5):313-26.