Refractory hepatic encephalopathy in a patient with hypothyroidism: Another element in ammonia metabolism

Table 2 Clinical cases of patients with hypothyroidism and hyperammonaemia reported in the literature

Year	Ref.	Clinical presentation	Thyroid disease	Liver disease	Evolution
1992	Hitoshi et al[6]	Mild dementia, slow speech, hyperreflexia, dysmetria, asterixis with hyperammonaemia.	Hypothalamic hypothyroidism	Cirrhosis and portal hypertension	Thyroid hormone replacement improved:
		Progression to coma despite lactulose treatment.			Hypothyroidism
					Hyperammonaemia
					NRL disturbances
1999	De Nardo et al[7]	Hoarseness, fatigue, tongue swelling, myopathy. Hyperammonaemia.	Primary hypothyroidism	none	Thyroid hormone replacement improved:
					Hypothyroidism
					Hyperammonaemia
					Systemic symptoms and myopathy
2000	Thobe et al[8]	Coma, hyperammonaemia.	Primary hypothyroidism	Compensated cirrhosis	Thyroid hormone replacement improved:
		Unresponsive to lactulose.			Hypothyroidism
					Hyperammonaemia
					NRL disturbances
2001	Yamamoto et al[9]	Dysarthria, disorientation.	Primary hypothyroidism	Decompensated cirrhosis	Thyroid hormone replacement improved:
					Hypothyroidism
					Hyperammonaemia
					NRL disturbances
2007	Rimar et al[10]	Coma, hyperammonaemia. Unresponsive to lactulose.	Primary hypothyroidism	Compensated cirrhosis	Thyroid hormone replacement improved:
					Hypothyroidism
					Hyperammonaemia
					NRL disturbances
2007	Khairy et al[11]	Grade III hepatic encephalopathy.	Primary hypothyroidism	Decompensated cirrhosis	Thyroid hormone replacement improved:
					Hypothyroidism
					NRL disturbances
2012	Redkar et al[12]	Coma, hyperammonaemia. Unresponsive to lactulose.	Primary hypothyroidism	Decompensated cirrhosis	Thyroid hormone replacement improved:
					Hypothyroidism
					Hyperammonaemia
					NRL disturbances