Hepatic Encephalopathy Uncommonly Presenting by Epilepsy and Hemiparesis: A Case Report

Hepatic encephalopathy (HE) is a serious complication of cirrhosis that presents with a variety of neuropsychiatric disorders, including disorientation, asterixis and coma. Such neurological disorders are because of hyperammonemia. However, hepatic encephalopathy with neurological symptoms resembling epilepsy and hemiparesis is uncommon. We present a case of decompensated liver cirrhosis manifesting initially by epilepsy and hemiparesis.

Case Report: A 59-year-old male smoker known to be diabetic, which was well controlled, presented to our hospital with a chief complaint of epileptic attacks over the past 24 hours in addition to dizziness, sudden-onset left-sided weakness and disturbed level of consciousness with a Glasgow Coma Scale rating of 13. Brain CT scan and MRI revealed supratentorial white matter changes with no signs of stroke or bleeding. Electroencephalogram (EEG) showed diffuse slow wave rhythm. Initially, the patient was treated with antiepileptic drugs with no improvement. Laboratory examination suggested liver cirrhosis. Plasma ammonia levels upon admission were 2 times the normal value. Abdominal imaging showed chronic hepatopathy, portosystemic varices and splenomegaly. Upper endoscopy showed esophageal varices. Liver cirrhosis was confirmed by transient elastography. The aetiology of cirrhosis was considered metabolic. As a result, the diagnosis of HE was made. The symptoms were improved by adding lactulose and Rifaximin to antiepileptic treatment.

Conclusion: Though uncommon, hepatic encephalopathy, as a complication of liver cirrhosis, should be considered in patients presenting with epilepsy and hemiparesis. Antiepileptic drugs combined with lactulose are essential for treatment.