A 52-year-old woman 3 weeks status post orthotopic liver transplant was noted to have ST-segment elevation on telemetry. The posttransplant course had been complicated by acute rejection treated with increasing tacrolimus doses resulting in status epilepticus from tacrolimus toxicity. She was treated with intravenous fosphenytoin followed by progressively increasing doses of intravenous phenytoin. Fluconazole, vancomycin, and meropenem had also been started empirically owing to decreased immune function and low blood pressure. At the time of the electrocardiogram (Figure 1), the corrected phenytoin level was 26 μg/mL (normal range 10-20, μg/mL).
Johnson CJ, Scheinman MA, Turakhia MP. Bizarre and Wide QRS After Liver Transplant—Quiz Case. JAMA Intern Med. 2013;173(11):953. doi:10.1001/jamainternmed.2013.644a