CEFEPIME-INDUCED COTARD SYNDROME: A CASE REPORT

Abstract

Background: Cotard syndrome features nihilistic delusions about one’s body or existence and is typically related to severe depression though is rarely associated with medical or neurological insults. Case presentation: The patient was a 62-year-old male with no past psychiatric history and a past medical history of congestive heart failure and consequent renal failure who presented for scheduled heart and kidney transplantation. He was started on routine post-transplant ganciclovir and steroids. Due to postoperative hypotension, empiric cefepime was initiated to cover for septic shock. One week postoperatively, the patient stated “I am dead.” He elaborated that “an intern overdilated me” during transplantation and declined tacrolimus. The patient also reported visual hallucinations of green algae and bubbles. He denied depression and was attentive and oriented. He had a Bush-Francis score of 9. MRI brain revealed no acute changes. Low-dose haloperidol was initiated for psychosis. Cefepime was discontinued, but ganciclovir and steroids were continued. Two days later, the symptoms fully resolved. Discussion: This is the first reported case of Cotard syndrome as an acute transplant complication. Though corticosteroid-induced psychosis was initially suspected, cefepime neurotoxicity is the more likely explanation given the correlation between the antibiotic and symptom courses. Older age and renal dysfunction were risk factors. Conclusions: Cotard Syndrome can be an acute complication of solid organ transplantation, where renal impairment and polypharmacy are common. Transplantation teams and consult-liaison psychiatrists should work together to manage this syndrome.