A case of hyperammonemia due to urinary tract infection complicated by hypothyroidism

Abstract

An 84-year-old woman was transferred to our emergency department because of disturbance of consciousness by an ambulance. She was treated for Graves disease in her 20's, but the treatment has been discontinued. She regularly visited a family doctor for hypertension, hyperlipidemia, gastroesophageal reflux, and osteoporosis. Her regularly medications were: lansoprazole, metoclopramide, ethyl icosapentate, rosuvastatin calcium, mosapride citrate hydrate, magnesium hydroxide, alfacalcidol, risedronate sodium hydrate, meloxicam. One day before she came to our hospital, the patient visited her family doctor with complaining of lower abdominal pain, general fatigue, and low motivation. She received intravenous fluid for dehydration and was prescribed ciprofloxacin hydrochloride for diagnosis as cystitis. As she expressed suicidal ideation, sulpiride was administered for depression as well. On the following day, when the acquaintance visited the patient at home, the patient was A case of hyperammonemia due to urinary tract infection complicated by hypothyroidismHiroyuki Inoue 1 , Takuro Nakada 1 , Mizuho Namiki 2 , Arino Yaguchi 2 ABSTRACT We report a case of disturbance of consciousness due to hyperammonemia stemming from urinary tract infection with urease-producing bacteria and complicated with hypothyroidism. An 84-yearold woman visited her family doctor with a history of excessive fatigue and was prescribed ciprofloxacin hydrochloride for cystitis and sulpiride for depression. The following day, she was brought to our hospital in an ambulance because of disturbance of consciousness. Sulpiride poisoning was suspected, and she was admitted to our emergency department. Because blood tests suggested hyperammonemia (197 µg/dl) and hypothyroidism, she was administered Lactulose, branched-chain amino acids, and thyroid hormones. Neither liver disease nor portosystemic shunting was observed in the blood or the imaging tests. The consciousness level initially improved along with the ammonia levels, however it later deteriorated again as the ammonia levels increased. Because urinary tract infection was complicated, we started administering antimicrobials. As a result, the level of ammonia normalized, and the level of consciousness improved. Arthrobacter cumminsii was detected by urine culture. Thus, we made a diagnosis as hyperammonemia due to urinary tract infection with urease-producing bacteria. In addition, hypothyroidisim in the patient aggravated hyperammonemia. In cases of hyperammonemia unaccompanied by liver disease, urease-producing bacterial infection and/or hypothyroidism should be considered. (JJAAM. 2012; 23: 398-402)

A Rare Case of Hyperammonemia Caused by Urinary Tract Infection Due to Corynebacterium riegelii

“…Urease-producing bacteria include Corynebacterium species, Proteus species, Pseudomonas species, and Klebsiella species [ 5 ] . Corynebacterium urealyticum is frequently reported in this context [ 6 , 7 ]. It is known for its resistance to many antibiotics, including beta-lactams, and susceptibility to glycopeptide antibiotics like vancomycin and teicoplanin [ 8 ].…”

Hyperammonemia Due to Empyema

“…Hyperammonemia is a clinical condition that can produce altered consciousness and mainly occurs in patients with hepatic encephalopathy, urea cycle disorders, and organic acidemia but can also have drug-related causes and miscellaneous causes (1). Hyperammonemia due to obstructive urinary tract infection secondary to urease-producing bacteria has also been previously reported (2). However, there have been no case reports of hyperammonemia due to empyema in the English literature.…”