Abstracts

Rationale: Seizures are a known neurologic complication in post-liver transplant patients. The occurrence has been well documented in cases with toxic immunosuppressant levels and posterior reversible encephalopathy syndrome. We present two cases of refractory myoclonic and generalized tonic- clonic seizures in post- liver transplant patients. Methods: Medical record review of two patients with refractory myoclonic and generalized – tonic seizures. Literature review of post-liver transplant seizures and a vitamin B 6 deficiency associated seizures in adults. Results: Patient A and B underwent transplant for NASH and Alcoholic Hepatitis respectively. Patient A presented 6 months after transplant and Patient B presented 1 month after transplant. The patients had no prior history of seizures.  They were both being treated with tacrolimus at the time of seizure onset which was later switched for an alternate therapy.  Tacrolimus levels were 28.7 (Patient A) and 11.7 (Patient B) ng/ml with a recommended therapeutic range of (5- 20 ng/ml). Brain imaging was normal with no findings suggestive of posterior reversible encephalopathy syndrome and CSF profile was also normal. Interictal EEG showed a frequent generalized rhythmic delta pattern with admixed sharp waves. Ictal EEG showed evolution of this rhythmic delta pattern with admixed spikes, polyspikes and sharp waves followed by an EEG pattern consistent with generalized- tonic clonic activity. Ictal EEG was often initially obscured by significant motion artifact related myoclonic activity. Seizure semiology was characterized by intense fear and anxiety followed by myoclonic jerks involving the head and trunk primarily, and later generalized- tonic clonic activity. There was on average a delay of 10 minutes between the onset of myoclonic activity and generalized tonic- clonic activity. Patient A required phenytoin, levetiracetam, lacosamide and clobazam in order to control seizures. Patient B required phenytoin, levetiracetam,lacosamide, clobazam and topiramate  prior to the control of seizures. Patient B was found to be deficient in Vitamin B6 with a level of 1.6 microgram/liter with reference range (2.0 – 32.8 microgram/liter). Seizures in Patient B stopped shortly after supplementation with Vitamin B6. Patient A was not checked for Vitamin B 6 and did not receive supplementation. Conclusions: These cases are interesting due to the refractory nature of seizures, ill-defined etiology, similar seizure semiology and EEG findings, as well as the apparent response of Patient B to Vitamin B6 supplementation. Much more is known about Vitamin B 6 responsive seizures in neonates than acquired Vitamin B6 deficiency and seizures in adults. We recommend screening for Vitamin B 6 in adult post- liver transplant patients with refractory seizures especially those patients with a history of alcohol related liver failure. Funding: None