Drug-induced Neuropsychiatric Syndrome in a Liver Transplant Recipient: A Case Report

In postliver transplant patients, numerous factors may lead to the presentation of neuropsychiatric symptoms. These may include pre-existing hepatic encephalopathy, metabolic disturbances, adverse drug reactions, and complex drug-drug interactions. Differentiating among these potential causes is often challenging for the treating team. However, it is crucial because distinguishing between them directly impacts treatment choices and patient outcomes. The present case report discusses a young 24-year-old female who developed acute psychiatric disturbances in the early postoperative period following a liver transplant. Her presentation was characterised by agitation, disorganised behaviour, and confusion. This raised questions about whether the patient was experiencing post-transplant delirium or primary drug-induced neurotoxicity. Laboratory evaluations revealed elevated serum tacrolimus levels at the time of symptom onset. The patient was concurrently receiving high-dose corticosteroids as part of her immunosuppression and antifungal therapy with fluconazole, a potent inhibitor of Cytochrome P450 3A4 (CYP3A4). This is known to reduce tacrolimus metabolism and increase circulating drug concentrations. The patient’s symptoms showed marked improvement following timely pharmacological adjustments, including modifications to her immunosuppressive and antifungal regimens. This underscores the reversibility of these manifestations when identified early. Therefore, the present case highlights how the use of tacrolimus, corticosteroids, and fluconazole may synergistically precipitate neuropsychiatric complications. It emphasises the need for close monitoring of immunosuppressant levels, regular reviews of concomitant medications, a high index of suspicion for drugdrug interactions, and a multi-disciplinary team effort in postliver transplant patients exhibiting acute neuropsychiatric syndromes.