Acute paranoid psychosis as sole clinical presentation of hepatic artery thrombosis after living donor liver transplantation

Here we describe a case of hepatic artery thrombosis after living-donor liver transplantation which was not preceded by signs of liver failure but rather by an episode of acute psychosis. After re-transplantation the patient recovered without sequelae.This case highlights the need to remain cautious when psychiatric disorders occur in patients after liver transplantation. The diagnostic procedures should not be restricted to medical or neurological causes of psychosis alone but should also focus vascular complications related to orthotopic liver transplantation.Hepatic artery thrombosis (HAT) is the most frequent arterial complication in orthotopic liver transplantation (OLT) occurring in 2.5-6.8% of adult transplant recipients including adult living donor liver transplant recipients [1-3] with an increased incidence in pediatric and ABO-incompatible liver transplantation [4,5]. The clinical presentation of HAT varies depending on the time of onset after transplantation. Severe acidosis, fever, systematic inflammatory response syndrome, or hepatic failure may ensue in early HAT (less than one month after OLT), whereas presentation of late HAT may vary from biliary complications such as recurrent biliary sepsis and stenotic lesions of the biliary tract, to an asymptomatic clinical picture with a mild elevation of serum transaminases and bilirubin levels [2,6]. HAT may thus be indicated by elevated serum transaminases, prolonged prothrombin time, or elevated total bilirubin and may be confirmed by doppler ultrasonography or angiography. Although in approximately 47% HAT requires re-OLT, cases without progressive allograft failure arterial flow may be resolved by fibrinolysis, interventional treatment, or surgical thrombectomy [1]. Mortality of HAT may vary from 55.6% (early HAT) to 15% (late HAT) [2]. The most common cause for HAT is surgical technique but hemodynamic or immunologic factors, such as reperfusion injury, hypercoagulation, and viral infections have also