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Bega D, Vaitkevicius H, Boland TA, Murray M, Chou SHY. Fatal hyperammonemic brain injury from valproic Acid exposure. Case Rep Neurol 2012; 4:224-30. [PMID: 23275785 PMCID: PMC3531956 DOI: 10.1159/000345226] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Hyperammonemia is known to cause neuronal injury, and can result from valproic acid exposure. Prompt reduction of elevated ammonia levels may prevent permanent neurological injury. We report a case of fatal hyperammonemic brain injury in a woman exposed to valproic acid. Case A 38-year-old woman with schizoaffective disorder and recent increase in valproic acid dosage presented with somnolence and confusion and rapidly progressed to obtundation. Brain MRI showed diffuse bilateral restricted diffusion in nearly the entire cerebral cortex. She had normal liver function tests but serum ammonia level was severely elevated at 288 μmol/l. Genetic testing showed no mutation in urea cycle enzymes. Despite successful elimination of ammonia with hemodialysis she developed fatal cerebral edema. Conclusion Cerebral edema secondary to hyperammonemia is potentially reversible if recognized early. Ammonia excretion can be facilitated by initiation of hemodialysis and administration of scavenging agents (sodium phenylacetate and sodium benzoate). Severe hyperammonemia can result from valproic acid exposure even in the absence of hepatotoxicity or inborn errors of metabolism. It is important to check serum ammonia in any patient with encephalopathy who has had recent valproic acid exposure.
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Affiliation(s)
- Danny Bega
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass., USA
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An unusual cause of hyperammonemia in a critically ill patient. Intensive Care Med 2012; 39:336-7. [PMID: 23096430 DOI: 10.1007/s00134-012-2736-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2012] [Indexed: 01/09/2023]
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Hoffer LJ, Bistrian BR. Appropriate protein provision in critical illness: a systematic and narrative review. Am J Clin Nutr 2012; 96:591-600. [PMID: 22811443 DOI: 10.3945/ajcn.111.032078] [Citation(s) in RCA: 134] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Widely varying recommendations have been published with regard to the appropriate amount of protein or amino acids to provide in critical illness. OBJECTIVE We carried out a systematic review of clinical trials that compared the metabolic or clinical effects of different protein intakes in adult critical illness and comprehensively reviewed all of the available evidence pertinent to the safe upper limit of protein provision in this setting. DESIGN MEDLINE was searched for clinical trials published in English between 1948 and 2012 that provided original data comparing the effects of different levels of protein intake on clinically relevant outcomes and evidence pertinent to the safe upper limit of protein provision to critically ill adults. RESULTS The limited amount and poor quality of the evidence preclude conclusions or clinical recommendations but strongly suggest that 2.0-2.5 g protein substrate · kg normal body weight⁻¹ · d⁻¹ is safe and could be optimum for most critically ill patients. At the present time, most critically ill adults receive less than half of the most common current recommendation, 1.5 g protein · kg⁻¹ · d⁻¹, for the first week or longer of their stay in an intensive care unit. CONCLUSION There is an urgent need for well-designed clinical trials to identify the appropriate level of protein provision in critical illness.
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Affiliation(s)
- L John Hoffer
- Lady Davis Institute for Medical Research, Jewish General Hospital, McGill University, Montreal, Canada.
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Lin CH, Chi CH, Wu SY, Hsu HC, Chang YH, Huang YY, Chang CJ, Hong MY, Chan TY, Shih HI. Prognostic values of blood ammonia and partial pressure of ammonia on hospital arrival in out-of-hospital cardiac arrests. Am J Emerg Med 2012; 31:8-15. [PMID: 22795429 DOI: 10.1016/j.ajem.2012.04.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2012] [Revised: 04/04/2012] [Accepted: 04/28/2012] [Indexed: 01/09/2023] Open
Abstract
PURPOSES Outcome prediction for out-of-hospital cardiac arrest (OHCA) is of medical, ethical, and socioeconomic importance. We hypothesized that blood ammonia may reflect tissue hypoxia in OHCA patients and conducted this study to evaluate the prognostic value of ammonia for the return of spontaneous circulation (ROSC). METHODS This prospective, observational study was conducted in a tertiary university hospital between January 2008 and December 2008. The subjects consisted of OHCA patients who were sent to the emergency department (ED). The primary outcome was ROSC. The prognostic values were calculated for ammonia levels and the partial pressure of ammonia (pNH(3)), and the results were depicted as a receiver operating characteristics curve with an area under the curve. RESULTS Among 119 patients enrolled in this study, 28 patients (23.5%) achieved ROSC. Ammonia levels and pNH(3) in the non-ROSC group were significantly higher than those in the ROSC group (167.0 μmol/L vs 80.0 μmol/L, P < .05; 2.61 × 10(-5) vs 1.67 × 10(-5) mm Hg, P < .05, respectively). The predictive capacity of area under the curve for ammonia and pNH(3) for non-ROSC was 0.85 (95% confidence interval, 0.75-0.95) and 0.73 (95% confidence interval, 0.61-0.84), respectively. The multivariate analysis confirmed that ammonia and pNH(3) are independent predictors of non-ROSC. The prognostic value of ammonia was better than that of pNH(3). The cutoff level for ammonia of 84 μmol/L was 94.5% sensitive and 75.0% specific for predicting non-ROSC with a diagnostic accuracy of 89.9%. CONCLUSIONS Hyperammonemia on ED arrival is independently predictive of non-ROSC for OHCA patients. The findings may offer useful information for clinical management.
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Affiliation(s)
- Chih-Hao Lin
- Department of Emergency Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70403, Taiwan.
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Häberle J, Boddaert N, Burlina A, Chakrapani A, Dixon M, Huemer M, Karall D, Martinelli D, Crespo PS, Santer R, Servais A, Valayannopoulos V, Lindner M, Rubio V, Dionisi-Vici C. Suggested guidelines for the diagnosis and management of urea cycle disorders. Orphanet J Rare Dis 2012; 7:32. [PMID: 22642880 PMCID: PMC3488504 DOI: 10.1186/1750-1172-7-32] [Citation(s) in RCA: 362] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 04/06/2012] [Indexed: 12/11/2022] Open
Abstract
Urea cycle disorders (UCDs) are inborn errors of ammonia detoxification/arginine synthesis due to defects affecting the catalysts of the Krebs-Henseleit cycle (five core enzymes, one activating enzyme and one mitochondrial ornithine/citrulline antiporter) with an estimated incidence of 1:8.000. Patients present with hyperammonemia either shortly after birth (~50%) or, later at any age, leading to death or to severe neurological handicap in many survivors. Despite the existence of effective therapy with alternative pathway therapy and liver transplantation, outcomes remain poor. This may be related to underrecognition and delayed diagnosis due to the nonspecific clinical presentation and insufficient awareness of health care professionals because of disease rarity. These guidelines aim at providing a trans-European consensus to: guide practitioners, set standards of care and help awareness campaigns. To achieve these goals, the guidelines were developed using a Delphi methodology, by having professionals on UCDs across seven European countries to gather all the existing evidence, score it according to the SIGN evidence level system and draw a series of statements supported by an associated level of evidence. The guidelines were revised by external specialist consultants, unrelated authorities in the field of UCDs and practicing pediatricians in training. Although the evidence degree did hardly ever exceed level C (evidence from non-analytical studies like case reports and series), it was sufficient to guide practice on both acute and chronic presentations, address diagnosis, management, monitoring, outcomes, and psychosocial and ethical issues. Also, it identified knowledge voids that must be filled by future research. We believe these guidelines will help to: harmonise practice, set common standards and spread good practices with a positive impact on the outcomes of UCD patients.
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Affiliation(s)
- Johannes Häberle
- University Children’s Hospital Zurich and Children’s Research Centre, Zurich, 8032, Switzerland
| | - Nathalie Boddaert
- Radiologie Hopital Necker, Service Radiologie Pediatrique, 149 Rue De Sevres, Paris 15, 75015, France
| | - Alberto Burlina
- Department of Pediatrics, Division of Inborn Metabolic Disease, University Hospital Padua, Via Giustiniani 3, Padova, 35128, Italy
| | - Anupam Chakrapani
- Birmingham Children’s Hospital NHS Foundation Trust, Steelhouse Lane, Birmingham, B4 6NH, United Kingdom
| | - Marjorie Dixon
- Dietetic Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, WC1N 3JH, United Kingdom
| | - Martina Huemer
- Kinderabteilung, LKH Bregenz, Carl-Pedenz-Strasse 2, Bregenz, A-6900, Austria
| | - Daniela Karall
- University Children’s Hospital, Medical University Innsbruck, Anichstrasse 35, Innsbruck, 6020, Austria
| | - Diego Martinelli
- Division of Metabolism, Bambino Gesù Children’s Hospital, IRCCS, Piazza S. Onofrio 4, Rome, I-00165, Italy
| | | | - René Santer
- Universitätsklinikum Hamburg Eppendorf, Klinik für Kinder- und Jugendmedizin, Martinistr. 52, Hamburg, 20246, Germany
| | - Aude Servais
- Service de Néphrologie et maladies métaboliques adulte Hôpital Necker 149, rue de Sèvres, Paris, 75015, France
| | - Vassili Valayannopoulos
- Reference Center for Inherited Metabolic Disorders (MaMEA), Hopital Necker-Enfants Malades, 149 Rue de Sevres, Paris, 75015, France
| | - Martin Lindner
- University Children’s Hospital, Im Neuenheimer Feld 430, Heidelberg, 69120, Germany
| | - Vicente Rubio
- Instituto de Biomedicina de Valencia del Consejo Superior de Investigaciones Científicas (IBV-CSIC) and Centro de Investigación Biomédica en Red para Enfermedades Raras (CIBERER), C/ Jaume Roig 11, Valencia, 46010, Spain
| | - Carlo Dionisi-Vici
- Division of Metabolism, Bambino Gesù Children’s Hospital, IRCCS, Piazza S. Onofrio 4, Rome, I-00165, Italy
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Pillai U, Kahlon R, Sondheimer J, Cadnapaphorncai P, Bhat Z. A rare case of hyperammonemia complication of high-protein parenteral nutrition. JPEN J Parenter Enteral Nutr 2012; 37:134-7. [PMID: 22610979 DOI: 10.1177/0148607112447815] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hyperammonemia is a metabolic derangement that can be potentially fatal. Primary hyperammonemia due to urea cycle enzyme deficiency is usually discovered in neonates but rarely can present in adulthood. Late-onset manifestations of urea cycle disorders can go unnoticed, until they become life threatening. The authors report a 28-year-old man who developed hyperammonemia in the hospital following parenteral nutrition (PN), leading to cerebral edema, which was fatal despite resolution of the hyperammonemia with cessation of PN and the use of continuous renal replacement therapy.
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107
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Imran M, Shah Y, Nundlall S, Roberts NB, Howse M. Is blood ammonia influenced by kidney function? A prospective study. Clin Biochem 2012; 45:363-5. [DOI: 10.1016/j.clinbiochem.2011.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Revised: 12/15/2011] [Accepted: 12/18/2011] [Indexed: 12/31/2022]
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Abstract
Ammonia is produced continuously in the body. It crosses the blood-brain barrier readily and at increased concentration it is toxic to the brain. A highly integrated system protects against this: ammonia produced during metabolism is detoxified temporarily by incorporation into the non-toxic amino acid glutamine. This is transported safely in the circulation to the small intestine, where ammonia is released, carried directly to the liver in the portal blood, converted to non-toxic urea and finally excreted in urine. As a result, plasma concentrations of ammonia in the systemic circulation are normally very low (<40 μmol/L). Hyperammonaemia develops if the urea cycle cannot control the ammonia load. This occurs when the load is excessive, portal blood from the intestines bypasses the liver and/or the urea cycle functions poorly. By far, the commonest cause is liver damage. This review focuses on other causes in adults. Because they are much less common, the diagnosis may be missed or delayed, with disastrous consequences. There is effective treatment for most of them, but it must be instituted promptly to avoid fatality or long-term neurological damage. Of particular concern are unsuspected inherited defects of the urea cycle and fatty acid oxidation presenting with catastrophic illness in previously normal individuals. Early identification of the problem is the challenge.
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Affiliation(s)
- Valerie Walker
- Department of Clinical Biochemistry, University Hospital Southampton NHS Foundation Trust, C Level MP 8, South Block, Southampton Hospital, Tremona Road, Southampton SO16 6YD, UK.
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Kasai A, Nagao K, Kikushima K, Watanabe K, Tachibana E, Soga T, Mastsuzaki M, Yagi T. Prognostic Value of Venous Blood Ammonia in Patients With Out-of-Hospital Cardiac Arrest. Circ J 2012; 76:891-9. [DOI: 10.1253/circj.cj-11-0449] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Asuka Kasai
- Department of Emergency Care, Surugadai Nihon University Hospital
| | - Ken Nagao
- Department of Cardiology, Resuscitation and Emergency Cardiovascular Care, Surugadai Nihon University Hospital
| | - Kimio Kikushima
- Department of Cardiology, Resuscitation and Emergency Cardiovascular Care, Surugadai Nihon University Hospital
| | - Kazuhiro Watanabe
- Department of Cardiology, Resuscitation and Emergency Cardiovascular Care, Surugadai Nihon University Hospital
| | - Eizo Tachibana
- Department of Cardiology, Resuscitation and Emergency Cardiovascular Care, Surugadai Nihon University Hospital
| | - Taketomo Soga
- Department of Cardiology, Resuscitation and Emergency Cardiovascular Care, Surugadai Nihon University Hospital
| | - Masakazu Mastsuzaki
- Department of Cardiology, Resuscitation and Emergency Cardiovascular Care, Surugadai Nihon University Hospital
| | - Tsukasa Yagi
- Department of Cardiology, Resuscitation and Emergency Cardiovascular Care, Surugadai Nihon University Hospital
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Affiliation(s)
- Prasad Bichu
- Division of Nephrology; Department of Internal Medicine; University of Missouri; Columbia; Missouri; USA
| | - Gautam Phadke
- Division of Nephrology; Department of Internal Medicine; University of Missouri; Columbia; Missouri; USA
| | - Harbaksh Sangha
- Division of Nephrology; Department of Internal Medicine; University of Missouri; Columbia; Missouri; USA
| | - Madhukar Misra
- Division of Nephrology; Department of Internal Medicine; University of Missouri; Columbia; Missouri; USA
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Hung TY, Chen CC, Wang TL, Su CF, Wang RF. Transient hyperammonemia in seizures: a prospective study. Epilepsia 2011; 52:2043-9. [PMID: 21972984 DOI: 10.1111/j.1528-1167.2011.03279.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To investigate the incidence and duration of transient hyperammonemia in seizures and to verify the significant confounders related to transient hyperammonemia in seizures. METHODS One hundred twenty-one noncirrhotic adult patients with seizures admitted to the emergency department were enrolled in the study. Laboratory examination was performed, including plasma ammonia level assessment. In addition, the basic parameters, underlying systemic diseases, and seizure-related conditions were assessed. The patients were classified into a group with hyperammonemia on arrival and a group without, in order to compare seizure-related adverse events that occurred during a 9-month period. KEY FINDINGS The incidence of hyperammonemia in patients with seizures was 67.77%. Plasma ammonia levels in patients with generalized tonic-clonic (GTC) seizures were significantly higher than those in patients in the non-GTC seizure group (median 174.5 vs. 47 μg/dl; proportion 76.5% vs. 21.1%; p < 0.001). Median plasma ammonia levels decreased spontaneously from 250 to 54 μg/dl (p < 0.00001) in an average interval of 466.79 min. GTC seizures (p < 0.0001), male gender (p < 0.0001), bicarbonate (p < 0.0001), diabetes (p = 0.0139), and alcohol-related seizures (p = 0.0002) were significant factors associated with hyperammonemia on arrival. No significant differences related to admission rates or mortalities were found between the two groups. SIGNIFICANCE The presence of transient hyperammonemia in patients with seizures is significantly related to GTC seizures, male gender, bicarbonate, diabetes, and alcohol-related seizures. The appropriate period to study ammonia levels following a seizure event is within 8 h. Because these phenomena are self-limited, ammonia-lowering management are not necessary. Hyperammonemia on arrival is not necessarily related to adverse outcomes.
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Affiliation(s)
- Tzu-Yao Hung
- Emergency Department, Keelung Hospital, Department of Health, Executive Yuan, Keelung, Taiwan
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113
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Abstract
Adult hyperammonaemia is associated with severe liver disease in 90% of cases. In the remainder, noncirrhotic causes should be considered. Measurements of serum ammonia level must be part of the basic work-up in all patients presenting with encephalopathy of unknown origin, even when liver function is normal. Clinician awareness of noncirrhotic hyperammonaemic encephalopathy can contribute to early diagnosis and the initiation of sometimes life-saving treatment. This review focuses on the physiology, aetiology and underlying mechanisms of noncirrhotic hyperammonaemic encephalopathy and discusses the available treatment modalities.
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Affiliation(s)
- Ido Laish
- Department of Internal Medicine A and Rabin Medical Center, Beilinson Hospital, Petah Tiqwa, Israel
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115
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Abstract
UNLABELLED Hyperammonemia is encountered frequently in acutely ill children presenting for emergency care with altered levels of consciousness (ALOC). Ammonia production, metabolism, and excretion are affected by different variables. Hyperammonemia may be a transient state or may signify more grave etiologies as inborn errors of metabolism. Levels of ammonia are also affected by proper sampling technique, transport, and analysis. OBJECTIVES To determine the level of ammonia in acutely ill children with ALOC, identify causes of hyperammonemia, and correlate levels with illness severity and morbidity. DESIGN Observational study. SETTING Emergency department at Cairo University Specialized Paediatric Hospital. METHODS Fifty cases of acutely ill pediatric patients with ALOC who presented to the emergency department were included in the study from 2008 through 2009. Emergency department patients (n = 20) with known diseases that may induce hyperammonemia were excluded. Patients were subjected to detailed history taking with emphasis on factors affecting ammonia levels and thorough clinical examination. A cohort group of age- and sex-matched children acted as a control group. RESULTS The measured blood ammonia level ranged between 13 and 265 μmol/L, with a mean level of 95 μmol/L. Sixty percent of the children with ALOC had ammonia levels of greater than 75 μmol/L, with levels greater than 200 μmol/L seen in 6% of the studied sample. The study demonstrated a highly significant statistical difference between children with ALOC and control groups.There was no correlation between blood ammonia level and age. Correlations of ammonia levels were also conducted in comparison with etiological diagnoses and laboratory parameters with no statistical significance.There was no statistical significance between ammonia level and duration of illness, Sequential Organ Failure Assessment score, or Glasgow Coma Scale score/Morray Scale score. CONCLUSIONS Clinicians should consider testing children with ALOC for hyperammonemia, provided that a clear understanding of its metabolism and factors controlling it are understood. Proper sampling must be ensured. Mild elevations of ammonia levels are fairly common, but exceedingly high levels should raise concern and may require further evaluation.
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U-King-Im JM, Yu E, Bartlett E, Soobrah R, Kucharczyk W. Acute hyperammonemic encephalopathy in adults: imaging findings. AJNR Am J Neuroradiol 2010; 32:413-8. [PMID: 21087942 DOI: 10.3174/ajnr.a2290] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE Acute hyperammonemic encephalopathy has significant morbidity and mortality unless promptly treated. We describe the MR imaging findings of acute hyperammonemic encephalopathy, which are not well-recognized in adult patients. MATERIALS AND METHODS We retrospectively reviewed the clinical and imaging data and outcome of consecutive patients with documented hyperammonemic encephalopathy seen at our institution. All patients underwent cranial MR imaging at 1.5T. RESULTS Four patients (2 women; mean age, 42 ± 13 years; range, 24-55 years) were included. Causes included acute fulminant hepatic failure, and sepsis with a background of chronic hepatic failure and post-heart-lung transplantation with various systemic complications. Plasma ammonia levels ranged from 55 to 168 μmol/L. Bilateral symmetric signal-intensity abnormalities, often with associated restricted diffusion involving the insular cortex and cingulate gyrus, were seen in all cases, with additional cortical involvement commonly seen elsewhere but much more variable and asymmetric. Involvement of the subcortical white matter was seen in 1 patient only. Another patient showed involvement of the basal ganglia, thalami, and midbrain. Two patients died (1 with fulminant cerebral edema), and 2 patients survived (1 neurologically intact and the other with significant intellectual impairment). CONCLUSIONS The striking common imaging finding was symmetric involvement of the cingulate gyrus and insular cortex in all patients, with more variable and asymmetric additional cortical involvement. These specific imaging features should alert the radiologist to the possibility of acute hyperammonemic encephalopathy.
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Affiliation(s)
- J M U-King-Im
- Department of Diagnostic Imaging, University Health Network, University of Toronto, Ontario, Canada.
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Chen YH, Chiou TJ, Hsu YN, Liu CY. Idiopathic hyperammonemia after chemotherapy with vinorelbine, topotecan, and cisplatin in a patient with acute lymphocytic leukemia. Hematol Oncol Stem Cell Ther 2010; 3:199-202. [DOI: 10.5144/1658-3876.2010.199] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Abstract
The acutely septic patient is a multifaceted challenge for the anesthetist. Unlike most elective surgery patients, acutely septic patients have severe systemic disease before the physiologic insults of anesthesia and surgery. The decision to operate is usually informed by the urgent or emergent need to correct a severe surgical problem and weighed against the higher risks of morbidity and mortality from the procedure itself. The care of the septic patient in the intensive care unit can help guide operating room management. However, the acuity and time course of intraoperative events, including hemorrhage and drug-induced shock states, compel the anesthetist to respond aggressively with therapies that may or may not be strongly substantiated with long-term data in the intensive care unit setting. The anesthesiologist must place considerations concerning short-term survival from the acute insult of surgery ahead of longer-term considerations.
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Affiliation(s)
- Jennifer E Hofer
- Department of Anesthesia and Critical Care, The University of Chicago Hospitals, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA.
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Wendell LC, Khan A, Raser J, Lang SS, Malhotra N, Kofke WA, LeRoux P, Park S, Levine JM. Successful Management of Refractory Intracranial Hypertension from Acute Hyperammonemic Encephalopathy in a Woman with Ornithine Transcarbamylase Deficiency. Neurocrit Care 2010; 13:113-7. [DOI: 10.1007/s12028-010-9361-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Thurlow VR, Asafu-Adjaye M, Agalou S, Rahman Y. Fatal ammonia toxicity in an adult due to an undiagnosed urea cycle defect: under-recognition of ornithine transcarbamylase deficiency. Ann Clin Biochem 2010; 47:279-81. [PMID: 20406775 DOI: 10.1258/acb.2010.009250] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
There is a lack of awareness of acutely presenting inborn errors of metabolism in adults, of which the X-linked urea cycle defect ornithine transcarbamylase (OTC) deficiency is an example, many comparatively mild mutations having been identified. In male hemizygotes clinical manifestations and age at presentation vary and depend on the mutation. In female heterozygotes the clinical spectrum depends on the extent to which the abnormal gene is expressed. Milder versions of the defect may not cause clear clinical symptoms and may remain unrecognized until the person is subjected to an unusually high nitrogen load when they develop severe hyperammonaemia. During acute episodes liver enzymes may be normal or only slightly elevated and occasionally accompanied by coagulopathy, but the key finding is hyperammonaemia. Boys with these milder forms may exhibit abnormal behaviour and be diagnosed with attention deficit hyperactivity disorder. This case illustrates how late presentation of OTC deficiency in a non-specialist centre can be difficult to differentiate from drug abuse, psychiatric illness or encephalopathy. Failure to measure blood ammonia in adults with unexplained key symptoms - particularly prolonged vomiting without diarrhoea and altered mental state/hallucinations, or to recognize the significance of elevated blood ammonia without evidence of liver decompensation can lead to delayed or missed diagnosis.
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Affiliation(s)
- Vanessa R Thurlow
- Department of Chemical Pathology, St Luke's Hospital, 801 Ostrum Street, Bethlehem, PA 18015, USA.
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Khoo CL, Naik S, Lua R, Chai SB, Liew A, Sim K. Valproate-induced hyperammonemia in mental retardation: a case report and review of the literature. Prog Neuropsychopharmacol Biol Psychiatry 2010; 34:561-2. [PMID: 20184937 DOI: 10.1016/j.pnpbp.2010.02.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 02/17/2010] [Accepted: 02/17/2010] [Indexed: 01/09/2023]
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Leitch AW, Williams M. The Use of Carnitine Rather than Renal Replacement Therapy for Sodium Valproate Poisoning. J Intensive Care Soc 2010. [DOI: 10.1177/175114371001100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Valproate toxicity can be complicated by the development of hyperammonaemia, which can cause cerebral oedema and encephalopathy. We report the successful management of a case of valproate overdose using carnitine and review the metabolic pathways responsible for its therapeutic effects.
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Affiliation(s)
- Andrew William Leitch
- Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust
| | - Matthew Williams
- Consultant Anaesthetist and Intensivist
- Department of Critical Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust
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Moderate hypothermia with intracranial pressure monitoring as a therapeutic paradigm for the management of acute liver failure: a systematic review. Intensive Care Med 2009; 36:210-3. [PMID: 19847396 DOI: 10.1007/s00134-009-1702-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Accepted: 10/05/2009] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To systematically review the literature and present data on the safety and efficacy of induced moderate hypothermia combined with ICP monitoring in critically ill patients with acute liver failure. DESIGN We conducted a retrospective observational search of MEDLINE database using both OVID and PubMed with the following MeSH terms, "Hypothermia, Induced," "Brain Edema," "Intracranial Hypertension" (ICH), "Liver failure, Acute" and "Liver Failure, Fulminant." We limited our search to case series involving at least three human subjects and all other clinical trials. Baseline ICP, cerebral perfusion pressure (CPP) and cerebral blood flow (CBF) as well as the response of these variables to hypothermia were recorded when available. Additional clinical and demographic data were also recorded. RESULTS Five case series were identified. Pre-existing coagulopathy from liver failure was reversed by various modalities in all studies prior to insertion of ICP monitors. Induction of moderate hypothermia combined with ICP monitoring consistently improved ICP, CPP and CBF in four trials; one trial demonstrated the feasibility and effectiveness of moderate induced hypothermia as part of a protocolized strategy for the management of ICH. CONCLUSIONS Limited data exist concerning the safety and efficacy of moderate hypothermia and ICP monitoring for the treatment of ICH in acute liver failure. The available evidence shows that induction of moderate hypothermia in this clinical setting is feasible and possibly efficacious. Well-designed prospective clinical trials are warranted in this challenging context, given the potential of providing a bridge to liver transplantation or even clinical recovery.
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Erinjeri JP, Deodhar A, Thornton RH, Allen PJ, Getrajdman GI, Brown KT, Sofocleous CT, Reidy DL. Resolution of hepatic encephalopathy following hepatic artery embolization in a patient with well-differentiated neuroendocrine tumor metastatic to the liver. Cardiovasc Intervent Radiol 2009; 33:610-4. [PMID: 19756861 DOI: 10.1007/s00270-009-9698-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 08/17/2009] [Accepted: 08/18/2009] [Indexed: 12/21/2022]
Abstract
Hepatic encephalopathy is considered a contraindication to hepatic artery embolization. We describe a patient with a well-differentiated neuroendocrine tumor metastatic to the liver with refractory hepatic encephalopathy and normal liver function tests. The encephalopathy was refractory to standard medical therapy with lactulose. The patient's mental status returned to baseline after three hepatic artery embolization procedures. Arteriography and ultrasound imaging before and after embolization suggest that the encephalopathy was due to arterioportal shunting causing hepatofugal portal venous flow and portosystemic shunting. In patients with a primary or metastatic well-differentiated neuroendocrine tumor whose refractory hepatic encephalopathy is due to portosystemic shunting (rather than global hepatic dysfunction secondary to tumor burden), hepatic artery embolization can be performed safely and effectively.
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Affiliation(s)
- Joseph P Erinjeri
- Interventional Radiology Service, Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA.
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Adams EN, Marks A, Lizer MH. Carbamazepine-induced hyperammonemia. Am J Health Syst Pharm 2009; 66:1468-70. [DOI: 10.2146/ajhp080454] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
| | - Alla Marks
- Pharmacy Practice, and Division of Technology in Education
| | - Mitsi H. Lizer
- Pharmacy Practice, Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA
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Metzeler KH, Boeck S, Christ B, Hausmann A, Stemmler HJ, Parhofer KG, Ostermann H, Hiddemann W, Braess J. Idiopathic hyperammonemia (IHA) after dose-dense induction chemotherapy for acute myeloid leukemia: Case report and review of the literature. Leuk Res 2009; 33:e69-72. [DOI: 10.1016/j.leukres.2009.01.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 01/07/2009] [Accepted: 01/14/2009] [Indexed: 01/09/2023]
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Sehli S, Nugent KM, Samathanam CA, Alalawi R. An 18-Year-Old Woman With Hyperammonemia. Chest 2009; 135:869-871. [DOI: 10.1378/chest.08-1611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Lora-Tamayo J, Palom X, Sarrá J, Gasch O, Isern V, de Sevilla AF, Pujol R. Multiple Myeloma and Hyperammonemic Encephalopathy: Review of 27 Cases. ACTA ACUST UNITED AC 2008; 8:363-9. [DOI: 10.3816/clm.2008.n.054] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Turken O, Basekim C, Haholu A, Karagoz B, Bilgi O, Ozgun A, Kucukardali Y, Narin Y, Yazgan Y, Kandemir EG. Hyperammonemic encephalopathy in a patient with primary hepatic neuroendocrine carcinoma. Med Oncol 2008; 26:309-13. [PMID: 19031017 DOI: 10.1007/s12032-008-9121-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2008] [Accepted: 10/21/2008] [Indexed: 01/09/2023]
Abstract
A 53-year-old male patient was admitted to our hospital with abdominal pain in the right upper quadrant. There was no change in laboratory investigations other than a slight increase in serum levels of alkaline phosphatase (ALP), alanine aminotransferase (ALT), and gamma glutamyl transferase (GGT). Computed tomography (CT) of the abdomen showed multiple hepatic nodular lesions in the liver. Tru-cut biopsy of the lesions was reported as well-differentiated neuroendocrine carcinoma. The patient received sandostatin treatment. After a few days, the patient was hospitalized in the intensive care unit with disturbance of consciousness and clinical features suggestive of encephalopathy. Serum ammonia level was found highly elevated. After the treatment with L-ornithine-L-aspartate, a remarkable improvement in the level of patient's sensorium occurred as well as a reduction in serum ammonia level within a few days. Transarterial chemoembolization (TACE) was performed one week later. The patient's condition began to worsen along with increase in serum ammonia level and he died because of hyperammonemic encephalopathy. There are case reports of hyperammonemia with some malignancies such as multiple myeloma, plasma cell leukemia, and leiomyosarcoma, or in some patients who have received chemotherapy. This case may suggest an association between hyperammonemia and neuroendocrine tumors.
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Affiliation(s)
- Orhan Turken
- Medical Oncology Department, GATA Haydarpasa Training Hospital, Haydarpasa, Uskudar, Istanbul, Turkey.
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Acute hyperammonemic encephalopathy in adult onset ornithine transcarbamylase deficiency. Intensive Care Med 2008; 34:1922-4. [PMID: 18651132 DOI: 10.1007/s00134-008-1217-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2008] [Accepted: 06/19/2008] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To report the clinical manifestations of acute hyperammonemic encephalopathy in adult onset ornithine transcarbamylase deficiency (OTCD). DESIGN Case report. SETTING Intensive care unit of a tertiary medical centre. PATIENT A 48-year-old Caucasian male body builder who developed acute loss of consciousness after a febrile illness. INTERVENTIONS The patient was immediately started on hemodia-filtration, protein elimination and ammonia scavenging medications. MEASUREMENTS AND RESULTS Serum ammonium was elevated and plasma and urine amino acids had a pattern indicative of a urea cycle defect. DNA studies revealed a mutation of the urea cycle enzyme, ornithine transcarbamylase. The encephalopathy resolved and the patient slowly recovered though with some cognitive impairment. CONCLUSIONS Adult presentation of OTCD is rare and the mortality and morbidity rates are high. However, survival is possible with rapid correction of hyperammonemia. As the clinical manifestations are non-specific, a high index of suspicion is necessary for the correct diagnosis and management.
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