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Miller Fisher Variant of Guillain-Barré Syndrome Requiring a Cardiac Pacemaker in a Patient on Tacrolimus After Liver Transplantation

Staff Physician, Hospital Medicine Group, Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA

Ari J Cohen, MD

Staff Physician, Section of Abdominal Transplantation, Ochsner Clinic Foundation, New Orleans, LA

Steven J Zuckerman, MD

Director, Neurology Service, Baton Rouge General Medical Center

Sundararama R Vatsavai, MD

Staff Physician, Hospital Medicine Group, Baton Rouge General Medical Center

Jeremy S Pepper, MD

Resident, Emergency Medicine Residency Program, Louisiana State University, Baton Rouge

Venkatramana R Banda, MD

Staff Physician, Hospital Medicine Group, Baton Rouge General Medical Center

James D Eason, MD

Chairman, Section of Abdominal Transplantation, Ochsner Clinic Foundation

George E Loss, Jr, MD

Staff Physician, Section of Abdominal Transplantation, Ochsner Clinic Foundation

Richa Kaushik, MD

Clinical Associate, Hospital Medicine Group, Baton Rouge General Medical Center

Reprints: Dr. P Kaushik, Hospital Medicine Group, Baton Rouge General Medical Center, 3600 Florida Blvd., Baton Rouge, LA 70806-3889, fax 225/387-7700, kaushikprashant{at}hotmail.com

OBJECTIVE: To report a case of Miller Fisher syndrome (MFS), a variant of Guillain–Barré syndrome (GBS) necessitating the placement of a permanent cardiac pacemaker in a patient on tacrolimus after a cadaveric orthotopic liver transplantation.

CASE SUMMARY: A 46-year-old African American male, who had been receiving tacrolimus 4 mg/day orally for the preceding 6 months, developed a Miller Fisher variant of GBS (severe ataxia, ophthalmoplegia, areflexia). He developed symptomatic sinus pauses requiring a cardiac pacemaker. He improved substantially after cessation of tacrolimus and initiation of intravenous immunoglobulin therapy. The patient was not rechallenged with tacrolimus due to the clinical/ethical gravity of this probable adverse effect.

DISCUSSION: Although different types of neuropathies have been reported with the use of tacrolimus, to the best of our knowledge, this is the first case report of a Miller Fisher variant of GBS severe enough to cause dysautonomia requiring a cardiac pacemaker associated with the use of this drug. Causality assessment using the Naranjo probability scale revealed the adverse drug event was probable.

CONCLUSIONS: Tacrolimus was probably associated with a Miller Fisher variant of GBS necessitating the placement of a permanent cardiac pacemaker in this patient. MFS needs to be considered a potentially life-threatening adverse effect of tacrolimus therapy.

Key Words: Guillain–Barré syndrome, liver transplantation, Miller Fisher syndrome, tacrolimus

Published Online, April 24, 2005. www.theannals.com, DOI 10.1345/aph.1E676