title: Miller fisher variant of guillain-barre syndrome requiring a cardiac pacemaker in a patient on tacrolimus after liver transplantation.
abstract: OBJECTIVE
  To report a case of Miller Fisher syndrome (MFS), a variant of Guillain-Barre syndrome (GBS) necessitating the placement of a permanent cardiac pacemaker in a patient on tacrolimus after a cadaveric orthotopic liver transplantation.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Hospital Medicine Group, Department of Internal Medicine, Baton Rouge General Medical Center, Baton Rouge, LA 70806-3889, USA. kaushikprashant@hotmail.com
authors.forename: Prashant
authors.initials: P
authors.lastname: Kaushik
authors.forename: Ari J
authors.initials: AJ
authors.lastname: Cohen
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Zuckerman
authors.forename: Sundararama R
authors.initials: SR
authors.lastname: Vatsavai
authors.forename: Jeremy S
authors.initials: JS
authors.lastname: Pepper
authors.forename: Venkatramana R
authors.initials: VR
authors.lastname: Banda
authors.forename: James D
authors.initials: JD
authors.lastname: Eason
authors.forename: George E
authors.initials: GE
authors.lastname: Loss
authors.forename: Richa
authors.initials: R
authors.lastname: Kaushik
mesh_terms: D000961:Antilymphocyte Serum / Q000008:administration & dosage / Q000276:immunology / Q000627:therapeutic use; D002304:Cardiac Pacing, Artificial / Q000379:methods*; D006801:Humans; D016756:Immunoglobulins, Intravenous / Q000627:therapeutic use; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D019846:Miller Fisher Syndrome / Q000139:chemically induced / Q000175:diagnosis / Q000628:therapy*; D016559:Tacrolimus / Q000009:adverse effects* / Q000627:therapeutic use; D028761:Withholding Treatment
chemical_list: D000961:Antilymphocyte Serum; D016756:Immunoglobulins, Intravenous; D007166:Immunosuppressive Agents; D016559:Tacrolimus