A 67-year-old man with a history of daily cannabis use and renal transplant on tacrolimus with no prior seizures presented to an outside hospital with shoulder pain. Soon after receiving morphine sulfate injection in the emergency department, he became unresponsive and had right-sided limb jerking with right sided eye deviation. Electroencephalogram (EEG) revealed focal status epilepticus originating from the left temporal region. He was intubated and transferred for higher level of care.
During hospitalization, the patient remained encephalopathic and underwent workup including computed tomography of the head, magnetic resonance imaging of the brain, cerebrospinal fluid analysis and serum studies, which were negative for any pathology for seizure. Tacrolimus dose was increased due to competing phenytoin administration and the patient subsequently had another seizure. Tacrolimus was switched to cyclosporine and the patient began to show improvement clinically and on EEG. However, due to sub-therapeutic cyclosporine levels, he was switched back to tacrolimus and had another seizure. As a result, tacrolimus was discontinued again and the patient remained seizure free with continued improvement in mentation until his 3 month follow up.