Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Dec 26, 2020; 8(24): 6480-6486
Published online Dec 26, 2020. doi: 10.12998/wjcc.v8.i24.6480
Status epilepticus as an initial manifestation of hepatic encephalopathy: A case report
Bin Cui, Lin Wei, Li-Ying Sun, Wei Qu, Zhi-Gui Zeng, Ying Liu, Zhi-Jun Zhu
Bin Cui, Lin Wei, Wei Qu, Zhi-Gui Zeng, Ying Liu, Zhi-Jun Zhu, Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
Li-Ying Sun, Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Intensive Care Unit, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
Author contributions: Zhu ZJ and Sun LY conceived and designed the study; Cui B and Wei L were involved in concept/design, data collection, data analysis/interpretation and drafting and critical revising the manuscript; Qu W, Zeng ZG and Liu Y participated in performance of the research; All authors issued final approval for the version to be submitted.
Supported by Beijing Municipal Science & Technology Commission, No. Z181100001718220.
Informed consent statement: Informed written consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Zhi-Jun Zhu, MD, PhD, Chief Doctor, Professor, Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Xicheng District, Beijing 100050, China. zhu-zhijun@outlook.com
Received: September 11, 2020
Peer-review started: September 11, 2020
First decision: September 24, 2020
Revised: September 28, 2020
Accepted: October 20, 2020
Article in press: October 20, 2020
Published online: December 26, 2020
Processing time: 98 Days and 22.9 Hours
Abstract
BACKGROUND

Status epilepticus in patients with hepatic encephalopathy (HE) is a rare but serious condition that is refractory to antiepileptic drugs, and current treatment plans are vague. Diagnosis may be difficult without a clear history of cirrhosis. Liver transplantation (LT) is effective to alleviate symptoms, however, there are few reports about LT in the treatment of status epilepticus with HE. To our knowledge, this is the first report of status epilepticus present as initial manifestation of HE.

CASE SUMMARY

A 59-year-old woman with a 20-year history of heavy drinking was hospitalized for generalized tonic-clonic seizures. She reported no history of episodes of HE, stroke, spontaneous bacterial peritonitis, ascites or gastrointestinal bleeding. Neurological examination revealed a comatose patient, without papilledema. Laboratory examination suggested liver cirrhosis. Plasma ammonia levels upon admission were five times normal. Brain computed tomography (CT) was normal, while abdominal CT and ultrasound revealed mild ascites, liver cirrhosis and splenomegaly. Electroencephalography (EEG)showed diffuse slow waves rhythm, consistent with HE, and sharp waves during ictal EEG corresponding to clinical semiology of focal tonic seizures. The symptoms were reversed by continuous antiepileptic treatment and lactulose. She was given oral levetiracetam, and focal aware seizures occasionally affected her 10 mo after LT.

CONCLUSION

Status epilepticus could be an initial manifestation of HE. Antiepileptic drugs combined with lactulose are essential for treatment of status epilepticus with HE, and LT is effective to prevent the relapse.

Keywords: Status epilepticus; Hepatic encephalopathy; Decompensated alcoholic liver cirrhosis; Antiepileptic drugs; Liver transplantation; Case report

Core Tip: The incidence of status epilepticus with hepatic encephalopathy (HE) is low, but it is a life-threatening condition. To our best knowledge, this is the first report of status epilepticus present as the initial manifestation of HE. Appropriate antiepileptic drugs and lactulose are the keys to prevent neurological impairment in the early stage. The prognosis is closely related to timely identification and treatment of protopathic disease. In this case, antiepileptic drug treatment is still needed after liver transplantation, suggesting that liver transplantation does have a definite role in treating status epilepticus with HE based on decompensated alcoholic liver cirrhosis. Results at her 10 mo follow-up are encouraging.