A report describes a case of a 66-year-old female who got admitted due to altered mental status several hours before hospitalization. She suffered liver cirrhosis related to chronic hepatitis B infection for four months. The patient was confused and disoriented during the presentation. She had a history of hospitalization due to hepatic encephalopathy a week before current admission and got discharged with medications including oral third-generation cephalosporin antibiotic, furosemide, spironolactone, ursodeoxycholic acid, L-ornithine-L-aspartate, lactulose, proton pump inhibitor (PPI) and antacid.

On recent presentation, the patient showed a distended abdomen due to gross ascites, no symptoms of vomiting, diarrhea, constipation, hematemesis, and melena, or symptom suggestive of other sources of bleeding pre-hospitalization. She denied any history of fever or symptoms regarding urination and high protein content foods consumption.

Examination revealed that the patient was difficult to communicate with and slow to answer questions. She was also disoriented about time. Her Vitals were within normal limits. Other physical examination findings showed stigmata of chronic liver disease and Icteric sclera. She showed Asterixis movements.

Abdominal examination revealed grade III ascites with collateral vein formation. The liver and spleen couldn′t be evaluated due to marked abdominal distention.

Laboratory examination revealed leukocytosis with neutrophil predominance and low lymphocyte, mild normochromic normocytic anemia, and thrombocytopenia.

Her Neutrophil/lymphocyte ratio was high. The liver enzyme test was normal. Protein analysis showed a low albumin level and low albumin/globulin ratio. She also showed hyperbilirubinemia with direct bilirubin dominance. Her Prothrombin time was 6 seconds prolonged from the normal upper limit. 

Her Urinalysis examination showed elevated leukocyte esterase, elevated leukocyte sediment, and bacteriuria. Her Urine culture test was positive for Enterococcus faecalis. All other tests were normal.

Clinical and laboratory findings indicated that hepatic encephalopathy precipitated by urinary tract infection was the cause of her altered mental status. She received branched-chain amino acid infusion, Lornithin-L-aspartate, lactulose, and third-generation cephalosporin antibiotic intravenously; along with, Ursodeoxycholic acid for hyperbilirubinemia and diuretic to reduce water retention. Her features of encephalopathy completely reversed, and she received a discharge on the seventh hospital day.

Seputra DPGS et al. Recurrent hepatic encephalopathy precipitated by urinary tract infection in patient with liver cirrhosis: a case report. Int J Adv Med. 2021May;8(5):712-715.