Treatment-Refractory Mania with Psychosis in a Post-Transplant Patient on Tacrolimus: A Case Report

Ithman, Muaid; Malhotra, Kunal; Bordoloi, Meelie; Singh, Gurbir

doi:10.3121/cmr.2018.1409

Cited by 11 publications

(10 citation statements)

References 12 publications

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“…1,2,8,19 In most cases, after the CNI is decreased or switched to another agent, resolution of psychiatric symptoms occurs within days to weeks, and in some cases, clinicians were able to completely taper off the anti-psychiatric medications. [1][2][3]8,18,19 Tacrolimus, however, is the cornerstone of maintenance immunosuppression and one has to balance out the risks of acute rejection. As with our patient's case, others have reported a higher risk of acute rejection with tacrolimus cessation.…”

Section: Discussionmentioning

confidence: 99%

“… 1 , 2 Others have reported that it can occur years after KT but was associated with trough tacrolimus blood concentrations that were higher than normal for the patient. 8 , 18 , 19 …”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

“…[1][2][3] Calcineurin inhibitors (CNI) are known to cause neurotoxicity, and symptoms ranging from confusion, seizures, posterior reversible encephalopathy syndrome, and acute-onset psychosis have been reported. [1][2][3][4][5][6][7][8][9] Steroid-based regimens can contribute to neuropsychiatric changes, with symptoms ranging from mild affective, cognitive, or behavioral symptoms to florid psychotic episodes. 10 There is little guidance in the literature on how best to manage these patients.…”

Section: Introductionmentioning

confidence: 99%

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New-onset Psychosis in an Immunosuppressed Patient With Kidney Transplantation: An Educational Case Report

Mappin‐Kasirer

Hoffman

Sandal

2020

Can J Kidney Health Dis

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Rationale: New-onset psychosis in an immunosuppressed patient post-kidney transplantation (KT) is a diagnostic challenge. A broad differential diagnosis merits consideration; however, an approach to this differential diagnosis remains to be outlined in the literature. Also, when and how to modify the maintenance immunosuppressive regimen remains a significant area of controversy. Presenting concerns: A 23-year-old male, known for X-linked Alport syndrome for which he had undergone KT 1 year prior, presented with a 1-week history of disorganized speech, bizarre behavior, religious delusions, and visual hallucinations. Diagnoses: After ruling out infectious, metabolic, autoimmune, and structural causes, immunosuppressant medications were changed from tacrolimus to cyclosporine. The patient did not improve after this change, and a second opinion consultation with a transplant psychiatrist led to a diagnosis of primary first-episode psychosis, later refined to bipolar disorder type I. Interventions: The patient was started on risperidone, which led to a significant improvement in his symptoms. Outcomes: Twelve months after discharge, his mood and behavior had returned to baseline on aripiprazole, bupropion, and citalopram. However, he developed acute allograft rejection, prompting a change from cyclosporine back to tacrolimus, with stability of his mental state and graft function. Teaching points: This report offers learners an extensive and organized differential diagnosis to the work up of psychosis post kidney transplantation. A complete history, with input from collateral sources, and a systematic approach to the differential diagnosis, are crucial and should not be overshadowed by the risk of immunosuppressant-related neurotoxicity. We underscore the importance of multi-disciplinary management and comprehensive psychosocial assessment and re-assessment to refine the diagnosis. We also report the successful re-introduction of tacrolimus once the diagnosis of a primary psychiatric disorder is confirmed. Finally, we offer a simplified approach that can aid in distinguishing between a primary psychiatric diagnosis versus tacrolimus-associated psychosis.

show abstract

Section: Discussionmentioning

confidence: 99%

“… 1 , 2 Others have reported that it can occur years after KT but was associated with trough tacrolimus blood concentrations that were higher than normal for the patient. 8 , 18 , 19 …”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

New-onset Psychosis in an Immunosuppressed Patient With Kidney Transplantation: An Educational Case Report

Mappin‐Kasirer

Hoffman

Sandal

2020

Can J Kidney Health Dis

View full text Add to dashboard Cite

show abstract

“…reported mania in a 66-year-old renal-transplant recipient. [ 5 ] She had a history of bipolar disorder and developed mania 1.5 years after transplant. There is possibility of relapse in this patient.…”

mentioning

confidence: 99%