Clinical Reasoning: Agitation and psychosis in a patient after renal transplantation

Abstract

A 31-year-old woman was admitted for fever and altered mentation of unclear etiology 16 months after a renal transplant. This was her third admission in 4 months for fever of unclear etiology, but the current admission differed in that she also demonstrated short-term memory loss, dramatic mood swings, agitation, and paranoid delusions. Other significant medical history included nonHodgkin lymphoma in childhood for which she underwent 2 allogeneic stem cell transplants, chemotherapy, and whole-body radiation. She also developed postradiation kidney failure which necessitated a cadaveric kidney transplant followed by immunosuppression with tacrolimus 2 mg BID and mycophenolate 1 g BID. Questions for consideration:

Investigations in GABA A receptor antibody-associated encephalitis

“…However, it is interesting to note that posttransplant immunosuppressed patients can develop autoimmune encephalitis, as has been shown in patients with anti-NMDAR and anti-LGI1 encephalitis. 22,23 The development of anti-GABA A R encephalitis as postviral encephalitis (HSV1 and HHV6) expands the number of receptors that can be involved as targets of postviral brain autoimmunity. This and previous findings 24 support the concept of autoimmunity triggered by extensive antigen release by infected neurons undergoing degeneration.…”

Neurological Complications of Solid Organ Transplantation

“…[104][105][106] The complex balance of immune modulatory medical regimens of SOT recipients leads to unusual situations such as the recently described case of autoimmune anti-N-methyl-D-aspartate receptor (NMDAR) encephalitis developing in a renal transplant patient while the patient was receiving mycophenolate and tacrolimus. 107 Immunological sequelae of altered suppressive or antibiotic regimens may put the transplanted organ at risk. 36,37 As patients resume their normal lives including travel and zoonotic exposures, the diagnostic acumen of the hospitalist will have to expand to adapt to emerging infections.…”

Posttransplant autoimmune encephalitis

“…Three case reports of posttransplant anti-NMDAR encephalitis are described. One case occurred 16 months after kidney transplantation for radiation nephropathy preceded by HCT for non-Hodgkin lymphoma 5 ; the 2 other cases were after renal transplant for reflux nephropathy and pyelonephritis, respectively 2 , 3 ; all developed AE while taking immunosuppressants (mycophenolate, 3; prednisone, 2; tacrolimus, 1). Similar to our anti-NMDAR encephalitis patient, 2 cases had concurrent EBV infection detected in CSF potentially suggesting a post-infectious AE similar to post-HSV encephalitis or facilitation by blood-brain barrier breakdown with EBV infection or reactivation.…”

“…Autoimmune etiologies are not well recognized in this setting, although a few cases are described. 1 – 5 Herein, we report 3 patients with posttransplant autoimmune encephalitis (AE).…”