UNEXPECTED ENCEPHALOPATHY IN CHRONIC-RENAL-FAILURE - HYPERAMMONEMIA COMPLICATING ACUTE PERITONITIS

A woman with mild chronic renal insufficiency was being treated with g lucocorticoids for a presumed chronic inflammatory disease. She develo ped peritonitis arising from a pelvic abscess, which was drained witho ut complications. Unexpectedly, she became obtunded, and eventually, t he neurologic dysfunction was linked to hyperammonemia in spite of nor mal liver function tests. Hyperammonemia was only transiently controll ed in spite of protein restriction, repeated hemodialysis, and the use of biochemical means to reduce ammonia. A recurrent pelvic abscess wa s drained, and hyperammonemia disappeared. A review of ammonia and nit rogen metabolism indicates that bypassing the liver with shunting of a mmonia into the systemic circulation should be added to the causes of symptomatic hyperammonemia. Treatment requires the elimination of the bacteria.