2384 Unusual Cause of Encephalopathy in an Immediate Post Transplant Patient

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INTRODUCTION: Brain abscesses are a rare complication post liver transplantation. They can present as a wide array of symptoms that can include fever, headache, focal deficits, or altered mental status. Immunosuppression makes transplant patients more susceptible to a wide array of microorganisms. We present a case of Nocardia farsinica brain abscess in a patient 4 months after liver transplantation. CASE DESCRIPTION/METHODS: A 76-year-old male with known cirrhosis from fatty liver disease, and recent liver transplant presenting with acute encephalopathy. Four months earlier, the patient received a liver transplant secondary to Nash cirrhosis. His post-operative course showed no infectious complications. He did have issues with mobility and was placed in a rehab facility. He was on tacrolimus as well as azathioprine for immunosuppression. He had hyperkalemia at rehab and his trimethoprim–sulfamethoxazole was held. The patient's family brought him to the hospital for changes in mental status. The patient met sepsis criteria on admission. CT of the head showed multifocal hypoattenuation lesions. MRI with contrast was obtained which showed multiple peripherally enhancing lesions. On peripheral history he had fallen at rehab and developed a hematoma of his thigh. The fluid collection on his thigh which was aspirated. Culture results were concerning for Nocardia. Patient was presumed to have cerebral nocardiosis and was started on imipenem and trimethoprim–sulfamethoxazole. The culture confirmed Nocardia farcinica. During his hospital stay, patient's mental status gradually improved. He was discharged on imipenem and Bactrim. Repeat MRI one year later showed complete resolution of lesions. DISCUSSION: Nocardia intracranial abscesses represent a rare complication post liver transplantation; although, infection is a common cause of mortality following liver transplantation. Opportunistic infection prophylaxis is vital and his lapse was likely cause of this infection. Patients that present with fever require expansive evaluation for the common and uncommon infectious causes. Any transplant patient with new or changing headache or altered mental status require imaging of the CNS as well as a lumbar puncture. Imaging, physical exam, cultures and serologies can then further delineate the cause. Brain abscesses have high morbidity and mortality; therefore, prompt diagnosis and treatment is vital.