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Diarrhea in transplant patients is caused by several infectious and non-infectious etiologies (1). It is unpleasant and inconvenient for the patient, but severe diarrhea can lead to severe dehydration, acute graft dysfunction, and fluctuating immunosuppressive drug levels (2). Tacrolimus toxicity could lead to Posterior reversible encephalopathy syndrome (PRES) (3).
27-year lady who had a renal transplant in 2015 from a living-related donor. Her primary renal disease is focal segmental glomerulosclerosis (FSGS). She returned from Morocco with a history of severe diarrhea for eight weeks. She had lots of antidiarrheal tablets in Morocco that did not improve her symptom.
She was admitted to the hospital with acute graft dysfunction and severe dehydration. Creatinine level was 644 umol/L. We stopped Mycophenolate Mofetil (MMF), continued on Tacrolimus, and increased steroids.
Stool cultures, C.difficle, and Cryptosporidium tests turned up negative. On the second day, her tacrolimus level was markedly elevated at 11.9, so we decreased the Tacrolimus dose to half.
The patient complained of headaches and blurred vision; her blood pressure was around 165/95 mmHg, so amlodipine 5 mg was started.
A few days later, the tacrolimus level remained high at 8.9. Moreover, the patient had convulsions that were persistent and finally terminated by Phenytoin. MRI scan showed features of PRES. The patient was intubated and moved to ITU. Then CMV PCR turned up relatively high 1052210 IU/ml, and the patient started on intravenous gancyclovir.
The patient lost her graft and has become dialysis-dependent after a prolonged ITU admission.
CMV infection should be suspected and treated as early as possible when a transplant recipient presents with diarrhea.
Diarrhea is well known to increase Tacrolimus level, leading to PRES even without markedly elevated blood pressure. So, early stopping of Tacrolimus is crucial in such cases.