A 57-year-old woman with end-stage renal disease (ESRD) and a metastatic carcinoma
of the abdominal wall of unknown origin was admitted to the intensive care unit due
to coma one day after the first cycle of chemotherapy comprising cisplatin, leucovorin,
and 5-fluorouracil (5-FU, 2100 mg/m2 infusion for 44 hours). Laboratory examination revealed a serum ammonia level of
363 µmol per liter (reference range, 18 to 72). Despite lactulose and hemodialysis
therapy, coma persisted and her pupils dilated on the next day. A diffusion-weighted
magnetic resonance imaging (MRI) of the brain (Fig. A) showed symmetric hyperintensities in the bilateral cortices, thalamus, and basal
ganglion, which appeared hypointense in the corresponding apparent diffusion coefficient
map (Fig. B), suggesting true restricted diffusion. A T1-weighted sagittal image (Fig. C) showed severe brain swelling and herniation and sulcal effacement with tonsillar
(circle) and transtentorial herniation (arrow). The MRI findings are consistent with
acute hyperammonemic encephalopathy, which is an uncommon but serious adverse effect
of 5-FU therapy.
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References
- MRI Findings in acute hyperammonemic encephalopathy: Three cases of different etiologies: teaching point: To recognize MRI findings in acute hyperammonemic encephalopathy.J Belg Soc Radiol. 2020; 104: 9
- The role of RRT in hyperammonemic patients.Clin J Am Soc Nephrol. 2016; 11: 1872-1878
- Cerebral herniation from hyperammonemic cerebral edema: a potentially reversible neurological emergency.Neurocrit Care. 2019; 30: 681-685
Article info
Publication history
Published online: November 03, 2022
Accepted:
October 28,
2022
Received:
February 9,
2022
Identification
Copyright
© 2022 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.
