New-Onset Psychotic Episode as the Primary Manifestation One Week After Liver Transplantation: A Case Report and Comprehensive Review About the Risk Factors.

INTRODUCTION: Postoperative neurological and neuropsychiatric complications (NNC) after liver transplantation (LT) have become an important research concern, but the difficulties arise with the diagnosis of the majority subclinical form of NNC. CASE REPORT: We report a middle-aged man who developed fluctuating psychotic symptoms, marked personality change, and behavioral disturbance approximately one week after LT. No overt focal neurological deficits, such as hemiparesis, aphasia, or seizures, were observed. Brain MRI showed small periventricular/subcortical white-matter lesions with hyperintensity on T2WI and FLAIR images and punctate hyperintensity on DWI. The findings were interpreted as suggestive of suspected silent ischemic brain injury. Tacrolimus-related neurotoxicity, PRES, metabolic/hepatic encephalopathy, infection, seizure-related states, and alcohol-related encephalopathy were considered in the differential diagnosis. Contemporaneous tacrolimus trough levels and EEG data were unavailable, so tacrolimus neurotoxicity and non-convulsive seizure-related psychiatric symptoms could not be completely excluded. The patient received symptomatic psychiatric treatment and rehabilitation, and his neuropsychiatric symptoms gradually resolved, with stable liver function at the last follow-up. CONCLUSION: This case illustrates that suspected silent ischemic brain injury after LT may present primarily as fluctuating psychotic symptoms and personality or behavioral changes, and may be easily mistaken for postoperative delirium, calcineurin-inhibitor neurotoxicity, infection, or metabolic/hepatic encephalopathy. In atypical or high-risk patients, early brain MRI may help identify potential brain involvement and guide timely neurological and neuropsychiatric evaluation. KEY MESSAGE: New-onset psychotic symptoms after LT should not be automatically attributed to postoperative delirium. Even when MRI findings do not definitively confirm acute infarction, timely neuropsychiatric assessment and early brain MRI may help identify potential structural brain involvement in high-risk or atypical patients.