Noncirrhotic hyperammonemia causing relapsing altered mental status

Closure of a distal splenorenal shunt as a therapy for refractory hyperammonaemia in setting of neuropsychiatric symptoms

Before the widespread use of the transjugular intrahepatic portosystemic shunt, portal hypertension was addressed by the creation of an operative distal splenorenal shunt (DSRS). DSRS was largely regarded as a safe and effective therapy, though it did have a risk of precipitating hyperammonaemia and hepatic encephalopathy.A woman suffered a gunshot wound to the abdomen. This trauma led to portal vein thrombosis, cavernous transformation of the vein and eventually bleeding oesophageal varices from portal hypertension. A DSRS was created to decrease portal hypertension. Years later, she had profound depression with psychomotor slowing in the setting of hyperammonaemia. To reduce hepatic encephalopathy as a contributor to her neuropsychiatric condition, her shunt was closed. The hyperammonaemia resolved and neuropsychiatric symptoms improved.This case highlights several interesting clinical features, including portal hypertension due to chronic portal vein occlusion, cavernous transformation, a surgical DSRS causing hyperammonaemia and hepatic encephalopathy manifesting as neuropsychiatric symptoms.

Acute Plasma Cell Leukemia Presenting as Primary Hyperammonemic Encephalopathy

Primary plasma cell leukemia (PPCL) is a rare form of multiple myeloma (MM) and is a rare aggressive disease with a median overall survival of 6 - 11 months. We present a case of acute hyperammonemic encephalopathy as the initial presentation of PPCL in a 78-year-old woman to highlight an atypical presentation of this disorder.

Clostridium Difficile and Noncirrhotic Hyperammonnemia in a Patient With COVID-19 Infection

Clostridium difficile is a bacterial infection that usually presents with diarrhea and is mostly associated with previous antibiotics use. Patients with coronavirus disease 2019 (COVID-19) generally have respiratory symptoms but can also present with diarrhea. Noncirrhotic hyperammonemia is an infrequent presentation and is treated with lactulose. We report the case of a 40-year-old male who was admitted to our hospital with abdominal pain, diarrhea, shortness of breath, and confusion. During hospitalization, the patient tested positive for COVID-19 and C. difficile, and oral vancomycin was administered. His kidney functions improved, but he remained confused. His ammonia levels were elevated, and he was not treated with lactulose due to ongoing diarrhea secondary to C. difficile infection.

Undiagnosed Wilson's Disease and Fibromyalgia Masking Bowel Perforation

Wilson’s disease is a complex multi-organ disease characterized by impaired biliary excretion of copper and resulting deposition of excess copper in the liver and other organs. It has a wide range of clinical presentations, and diagnosis often requires a high degree of clinical suspicion, especially in patients with multiple other comorbidities.

We present the case of a 37-year-old woman with a complex medical and psychiatric history who was admitted for chronic diarrhea, hepatic enzyme elevation, electrolyte abnormalities, hyperammonemia, and methicillin-sensitive Staphylococcus aureus bacteremia. She was eventually found to have low serum ceruloplasmin level and elevated urine copper levels. Though confirmatory liver biopsy was not performed due to bowel wall rupture and septic shock, most of her symptoms and lab abnormalities could be explained by an underlying diagnosis of Wilson’s disease.

We present this case primarily as a cautionary tale. This patient was not lacking in medical attention prior to this prolonged hospitalization; however, her psychiatric issues and fibromyalgia management were the predominant foci during her frequent primary care office visits and likely distracted from the patient’s chronic laboratory abnormalities. More vigilant laboratory evaluation of underlying medical conditions in psychiatric patients may be warranted in order to prevent serious complications of such conditions.

A case of anti-VGKC antibody encephalitis and prolonged encephalopathy despite spontaneous resolution of imaging abnormalities

Anti-voltage-gated potassium channel (anti-VGKC) antibody encephalitis is a common form of autoimmune encephalitis (AE). AE is usually associated with autoimmune diseases or paraneoplastic phenomena such as seen in small cell lung cancer. Clinical presentation can include memory impairment, seizures, and psychiatric symptoms. We report a case of a 72-year-old male with non-small lung cancer in remission who presented with erosive gastritis and acute severe encephalopathy. Anti-VGKC antibody limbic encephalitis was diagnosed. Spontaneous resolution of encephalitis-associated changes on brain Magnetic Resonance (MR) with concomitant decreased circulating antibody levels were observed despite lack of overall cognitive improvement.

Abbreviations

AE: autoimmune encephalitis; AMPAR: antibody limbic encephalitis - anti-α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor encephalitis; Anti-VGKC encephalitis: anti-Voltage-gated potassium channel antibody encephalitis; CRP: c-reactive protein; CT: computed tomography; EEG: electroencephalography; ESR: erythrocyte sedimentation rate; GCS: Glasgow Coma Scale; MRImaging: Magnetic resonance imaging; NMDA-R encephalitis: Anti-N-methyl D-aspartate receptor encephalitis; PCR: polymerase chain reaction.

Non-cirrhotic Extra-Hepatic Porto-Systemic Shunt Causing Adult-Onset Encephalopathy Treated with Endovascular Closure

INTRODUCTION

Encephalopathy secondary to hyperammonemia due to Congenital Extra-hepatic Porto-systemic shunt (CEPS) in the absence of liver cirrhosis is an exceptionally unusual condition. We describe the case of a 54-year-old woman admitted to the Emergency Department complaining of recurrent episodes of confusion and worsening cognitive impairment. At admission, the patient displayed slowing cognitive-motor skills with marked static ataxia and impaired gait. Hyperammonemia was detected in the serum. An abdominal computed tomography (CT) excluded portal hypertension and liver cirrhosis, detecting a congenital extra-hepatic porto-systemic shunt which is a highly unusual vascular malformation. The patient was treated by interventional radiologists with a successful endovascular closure.

AREAS COVERED

We have performed a review of the last three decades of the literature, starting from the introduction of CT scanning in common clinical practice. Eighteen studies (case reports) described 29 patients with encephalopathy secondary to hyperammonemia due to CEPS in the absence of liver cirrhosis: They underwent treatment similar to our case report of CEPS.

EXPERT COMMENTARY

Encephalopathy secondary to hyperammonemia in the absence of hepatic dysfunction is an important diagnostic dilemma to many clinicians. An interventional radiologic approach is currently preferred.