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

Table 1 Anthropometric, laboratory, neuropsychological and spectroscopic data of the patient at hospital admission and 1 year after discharge

	March 2015	May 2016
Anthropometric
Weight in kg	75	72
BMI	28.2	27.7
Laboratory
Hb in g/dL	12.7	15.3
MCV	103.8	98.8
Leucocytes as 103/μL	3.9	5.7
Platelets as 103/μL	120	165
INR	1.18	1.14
AST in U/L	33	31
ALT in U/L	41	34
GGT in U/L	145	165
AP in U/L	90	116
Albumin in g/dL	3.3	4.3
Bilirubin in mg/dL	1	1.3
Creatinine in mg/dL	0.59	0.5
Na in mmol/L	139	144
Child-Pugh	B (7)	A (6)
MELD	8	9
Ammonia in μmol/L	62	23
Thyroid function
TSH in mUI/L	69.86	2.66
T4free in ng/dL	0.6
PHES
Symbol digit test as points	8	34
Number connection test A in s	78	25
Number connection test B in s	514	73
Serial dotting test in s	79	37
Line tracing test as seconds + errors	200	100
Final score	-9	1
Magnetic resonance spectroscopy
Glx/Cr	1.884	0.439
Cho/Cr	0.934	1.204
mI/Cr	0.064	0.529

ALT: Alanine aminotransferase; AP: Alkaline phosphatase; AST: Aspartate aminotransferase; BMI: Body mass index; Cho/Cr: Choline/creatine; GGT: Gamma-glutamine transferase; GLx/Cr: Glutamate-glutamine/creatine; Hb: Haemoglobin; INR International normalized ratio; MCV: Mean corpuscular volume; MELD: Model for end-stage liver disease; mI/Cr: Myoinositol/creatine; T4free: free thyroxine; TSH: Thyroid-stimulating hormone.

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