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Food Coma: Hyperammonemic Encephalopathy From Refeeding Syndrome. Cureus 2021 Oct;13(10):e18898

Date

11/26/2021

Pubmed ID

34820220

Pubmed Central ID

PMC8601258

DOI

10.7759/cureus.18898

Abstract

Hyperammonemic encephalopathy (HAE) from extrahepatic causes is increasingly being recognized. Refeeding syndrome is characterized by severe fluid and electrolyte shifts following the reintroduction of nutrition. We describe the case of a 67-year-old man with bilateral maxillary sinus squamous cell carcinoma on nivolumab who became comatose after initiation of enteral feeding. Initial workup was notable for severe hypophosphatemia (<1 mg/dL) and markedly elevated ammonia (226 ┬Ámol/L). Neuroimaging was unrevealing. Correction of hypophosphatemia did not improve mental status. Ammonia levels briefly decreased while holding enteral feeding but worsened again on resumption. High-volume continuous renal replacement therapy was recommended but deferred in accordance with family wishes. We hypothesize that HAE may have been precipitated by a combination of refeeding-induced high nitrogen burden and limited detoxification via the urea cycle and extrahepatic pathways in the setting of severe protein-energy malnutrition and underlying malignancy. Nivolumab could have contributed as well.

Author List

Khoory J, Rupal A, Jani C, Singh H, Hu K

Author

Kurt Hu MD Assistant Professor in the Medicine department at Medical College of Wisconsin