Status epilepticus as an initial manifestation of hepatic encephalopathy: A case report

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

Figure 1

Images of magnetic resonance imaging. A: T2-weighted magnetic resonance imaging showed mild hyperintensities in bilateral frontoparietal lobe on day 5; B: The magnetic resonance imaging scans revealed hyperintensities in bilateral frontoparietal lobe on fluid low attenuation inversion recovery-weighted sequences 5 d after onset; C: The lesion of hyperintensity was shown to be significantly reduced after 2 mo.

Figure 2

Electroencephalography showing different wave rhythms. A: Interictal electroencephalography showed slow wave rhythm activity; B: Epileptiform discharge (orange arrow) in left parietooccipital during ictal period, which corresponded well to the clinical symptoms; C: The slow waves rhythm and background activity improved after 2 mo.