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Ready to upload
Record number:
2350
Adverse Occurrence type:
MPHO Type:
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This is the first description of a case of deep hepatic encephalopathy via severe hyperammonemia and precipitated by fecal microbiota transplantation (FMT) that was provided for fulminant, refractory Clostridioides difficile infection (CDI).
Time to detection:
36 hours post-FMT
Alerting signals, symptoms, evidence of occurrence:
A 70-year-old woman was referred for FMT due to life threatening, fulminant CDI. Thirty-six hours post-FMT, the patient was found lying on the floor, disoriented. Upon immediate readmission, she was comatose. Plasma ammonia was elevated (419 mmol/L) compared with near-normal pre-FMT levels. Liver-derived coagulation factors (INR) were normal and bilirubin only marginally elevated. Brain CT scan ruled out cerebral bleeding and edema, abdominal CT scan revealed a complete portal vein thrombosis. Blood gas values, electrolytes, hemoglobin and inflammatory marker levels were normal. The insertion of a nasogastric tube was necessary. During 12 h of standard corrective treatment cerebral state improved (ammonia levels halved to 192 mmol/L) but unfortunately an uncontrollable nasopharyngeal bleed occurred, from which the patient died the day after admission.
Demonstration of imputability or root cause:
Hyperammonemia caused primarily by the rapid shift of a microbiota dominated largely by urease-negative Clostridium difficile to that resembling a healthy, intestinal donor microbiota possessing ample urease activity, together with a delayed ammonia clearance due to shunt-related decreased ammonia metabolism in a patient with preserved liver function. Dehydration from refractory CDI may have further enhanced this condition.
Imputability grade:
1 Possible
Keywords:
Reference attachment:
Suggest references:
Eriksen LL, Baunwall SMD, Eriksen PL, Bak-Fredslund KP, Nielsen JE, Dahlerup JF, Thomsen KL, Vilstrup H, Hvas CL. Deep hyperammonemic hepatic encephalopathy precipitated by fecal microbiota transplantation for fulminant Clostridioides difficile infection. Gastroenterol Rep (Oxf). 2021 Oct 15;10:goab043. doi: 10.1093/gastro/goab043. PMID: 35382170; PMCID: PMC8972992.
Expert comments for publication:
Hepatic encephalopathy is investigated as a potential indication for performing FMT in patients with established liver cirrhosis. The case report underpins the need for careful patient assessment, outweighing potential risks and benefits, and close monitoring and follow-up.