Tacrolimus
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Acute psychotic disorder: 2 case reports In a case series, 2 men aged 57–65 years were described, who developed acute psychotic disorder during treatment with tacrolimus. Case 1: A 65-year-old man had been diagnosed with alcoholic liver cirrhosis, 2 years prior to his referral for liver transplantation. He had experienced episodes of hepatic encephalopathy, for which he had been hospitalised twice. He had a history of alcohol abuse; however, he was in complete abstinence from alcohol for 8 years. He had been receiving spironolactone, furosemide, propranolol, ornithine-aspartate [L-ornithine l-aspartate], lactulose and folic-acid. His Child-Pugh score was 12 (class C) and a model for end-stage liver disease score was 25. Subsequently, he underwent orthotopic liver transplantation. On post-operative day 1, he started receiving immunosuppressive drug regimen including tacrolimus, mycophenolate and prednisone. On day 3, he was transferred from ICU and on day 7, he was discharged from the hospital to outpatient care. However, on post-operative day 19, he presented to the emergency department with chief complaints of confusion, insomnia, asthenia and upper extremities tremor. At that time, he had been receiving tacrolimus 7mg twice daily [route not stated], mycophenolate-mofetil, prednisone, omeprazole and cotrimoxazole [trimethoprim-sulfamethoxazole]. Blood test showed anaemia (haemoglobin 9.6 g/L), total bilirubin 0.7 mg/dL, sodium 143 mEq/L, calcium 8.7 mg/dL, magnesium 1.5 mEq/L, potassium 3.8 mEq/L, creatinine 0.7 mg/dL and a blood level of tacrolimus of 8 ng/mL. Markers of hepatic function and hepatic injury were all within the normal range and he had no clinical signs of infection. The neurologic examination showed symmetrical strength and sensitivity, preserved deep tendon reflexes and normal orientation in space and time. However, he described visual, auditory hallucinations of unknown individuals and delusions about family members and health care workers plotting to kill him. After 2 days of his admission, tacrolimus blood level was 11.4 ng/mL. He was diagnosed with acute psychotic disorder. Tacrolimus was stopped as it was considered to be the cause of psychotic symptoms, while other medications were continued. During the 24 hour period, he showed progressive improvement of the symptoms. All the symptoms were resolved within 1 day. After 2 days, he started receiving ciclosporin, with no adverse effects. He was discharged from hospital after 2 more days. At the time of report, he was alive with adequate graft function, using ciclosporin and mycophenolate mofetil as immunosuppressants Case 2: A 57-year-old man had been diagnosed with alcoholic liver cirrhosis, 10 year prior to his referral for liver transplantation. He previously had ascites, hepatic encephalopathy and 2 episodes of upper GI bleeding. For the past 3 years, his symptoms of liver disease were under control. Two years before, he had an ischemic stroke, with mild dysarthria. He had been receiving treatment for diabetes and hypertension, includi
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