Sainte Anne Hospital, Department of Neurointensive Care, Paris, France.
Fondation Ophtalmologique Adolphe de Rothschild, Department of Neurointensive Care, Paris, France.
J Crit Care. 2020 Jun;57:79-83. doi: 10.1016/j.jcrc.2020.02.003. Epub 2020 Feb 5.
Alert intensivists about the diagnostic pitfalls arising from hyperammonemia due to Ureaplasma infections in post-transplant patients.
Clinical observation of one patient.
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.
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.
提醒重症监护医生注意，在移植术后患者中，由于解脲脲原体感染导致高氨血症可能出现的诊断陷阱。
对一名患者进行临床观察。
一名 65 岁女性，有近期肾移植病史，因难治性癫痫持续状态入住重症监护病房。脑部影像学检查未见病变。脑脊液细菌培养和病毒 PCR 均为阴性。第 2 天测得的第 1 次血氨水平是正常值的 13 倍，但肝功能检查正常。持续升高的血氨水平导致开始进行症状性降氨治疗和连续性肾脏替代治疗，治疗后氨水平下降但未恢复正常。随后诊断为解脲脲原体感染。给予左氧氟沙星和多西环素治疗，48 小时内氨水平恢复正常。然而，重复 MRI 显示弥漫性皮质细胞毒性水肿，患者仍处于最小意识状态。4 个月后，患者因再次感染死亡。
在移植术后患者中，出现与肝功能衰竭无关的神经症状伴高氨血症时，应怀疑解脲脲原体感染。只有紧急治疗才能改善预后，防止严重的神经损伤或死亡。
