AUTHOR=Olivero Marco , Gagliardi Delia , Costamagna Gianluca , Velardo Daniele , Magri Francesca , Triulzi Fabio , Conte Giorgio , Comi Giacomo P. , Corti Stefania , Meneri Megi 

TITLE=Newly Diagnosed Hepatic Encephalopathy Presenting as Non-convulsive Status Epilepticus: A Case Report and Literature Review

JOURNAL=Frontiers in Neurology

VOLUME=Volume 13 - 2022

YEAR=2022

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2022.880068

DOI=10.3389/fneur.2022.880068

ISSN=1664-2295

ABSTRACT=Background: Hepatic encephalopathy is characterized by psychiatric and neurological abnormalities, including epileptic seizure, nonconvulsive and convulsive status epilepticus. Conventional brain magnetic resonance imaging is useful in supporting the diagnosis, since it can reveal specific radiological findings. In the literature, there is no description of hepatic encephalopathy onset as nonconvulsive status epilepticus; we provide the first report.
Case summary: We report a case of a 67-years old woman, without history of cirrhosis, presenting altered mental state, normal brain computed tomography imaging and electroencephalography suggestive of epileptic activity. We suspected nonconvulsive status epilepticus and we administered diazepam and levetiracetam with clinical improvement. Thus, we made a diagnosis of nonconvulsive status epilepticus. Radiological study with brain magnetic resonance imaging showed bilateral hyperintensity on T1-weighted sequences of globus pallidus and hyperintensity of both corticospinal tracts on T2-weighted fluid-attenuated inversion recovery sequences. Blood tests revealed hyperammonemia, mild abnormality of liver function indices, chronic Hepatitis B and D virus coinfection. Hepatic elastosonography suggested liver cirrhosis. The patient started antiviral therapy with entecavir and prevention of hepatic encephalopathy with rifaximin and lactulose; she was discharged with a normal mental state. 
Conclusions: Hepatic encephalopathy can present as initial manifestation with nonconvulsive status epilepticus. Electroencephalography is useful in differentiating nonconvulsive status epilepticus from an episode of hepatic encephalopathy and neuroimaging aids the diagnostic process.