Camille Legouy1, Alice Hu2, Fanny Mochel3, Nicolas Weiss4, Adrien Collin5, Sabine Pereyre6, Mathilde Perrin2, Nicolas Engrand7. 1. Sainte Anne Hospital, Department of Neurointensive Care, Paris, France. 2. Fondation Ophtalmologique Adolphe de Rothschild, Department of Neurointensive Care, Paris, France. 3. Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Department of Genetics, Paris, France. 4. Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière University Hospital, Department of Neurointensive Care, Paris, France. 5. Fondation Ophtalmologique Adolphe de Rothschild, Department of Neuroradiology, Paris, France. 6. French National Reference Center for bacterial STI, Pellegrin Hospital, Bordeaux, France. 7. Fondation Ophtalmologique Adolphe de Rothschild, Department of Neurointensive Care, Paris, France. Electronic address: nengrand@fo-rothschild.fr.
Abstract
PURPOSE: Alert intensivists about the diagnostic pitfalls arising from hyperammonemia due to Ureaplasma infections in post-transplant patients. MATERIALS AND METHODS: Clinical observation of one patient. CASE REPORT: A 65-year-old female with a medical history of semi-recent kidney transplant was admitted to the Intensive Care Unit for refractory status epilepticus. There were no lesions on brain imaging. Bacterial cultures and viral PCR of cerebrospinal fluid were negative. The first blood ammonia level measured on day 2 was 13 times the normal level, but biological liver tests were normal. The persistence of elevated ammonia levels led to the initiation of symptomatic ammonia lowering-treatments and continuous renal replacement therapy, which led to its decrease without normalization. An Ureaplasma spp infection was then diagnosed. Levofloxacin and doxycyline were administered resulting in normalization of ammonia levels within 48 h. However repeat MRI showed diffuse cortical cytotoxic edema and the patient remained in a minimally conscious state. She eventually died 4 months later from a recurrent infection. CONCLUSION: Ureaplasma infection must be suspected in cases of neurological symptoms associated with hyperammonemia without liver failure, following an organ transplant. Only urgent treatment could improve the prognosis and prevent severe neurological damage or death.
PURPOSE: Alert intensivists about the diagnostic pitfalls arising from hyperammonemia due to Ureaplasma infections in post-transplant patients. MATERIALS AND METHODS: Clinical observation of one patient. CASE REPORT: A 65-year-old female with a medical history of semi-recent kidney transplant was admitted to the Intensive Care Unit for refractory status epilepticus. There were no lesions on brain imaging. Bacterial cultures and viral PCR of cerebrospinal fluid were negative. The first blood ammonia level measured on day 2 was 13 times the normal level, but biological liver tests were normal. The persistence of elevated ammonia levels led to the initiation of symptomatic ammonia lowering-treatments and continuous renal replacement therapy, which led to its decrease without normalization. An Ureaplasma spp infection was then diagnosed. Levofloxacin and doxycyline were administered resulting in normalization of ammonia levels within 48 h. However repeat MRI showed diffuse cortical cytotoxic edema and the patient remained in a minimally conscious state. She eventually died 4 months later from a recurrent infection. CONCLUSION:Ureaplasma infection must be suspected in cases of neurological symptoms associated with hyperammonemia without liver failure, following an organ transplant. Only urgent treatment could improve the prognosis and prevent severe neurological damage or death.
Authors: Alexander Balcerac; Kevin Bihan; Bénédicte Lebrun-Vignes; Dominique Thabut; Joe-Elie Salem; Nicolas Weiss Journal: Ann Intensive Care Date: 2022-06-18 Impact factor: 10.318