dev/text_files_en/S0210-48062007000400012-1.txt

This is a 66-year-old diabetic woman with a history of hepatitis C of post-transfusion etiology.
In January 2006, the patient had a pertinacious voiding syndrome that did not respond to treatment. A cystoscopy with subsequent TURP was performed.
She was diagnosed with pTa G3 bladder carcinoma after which she began treatment with intravesical BCG.
Follow-up TURP after BCG treatment ended detected the presence of multiple foci of carcinoma in the bladder confirming the diagnosis of urothelial carcinoma affecting the muscular layer (pT2 G3).
In July 2006, she underwent a radical cystectomy with urinary diversion by means of a Mainz II type sigmoidostomy.
Pathology showed a high grade urothelial carcinoma with invasion of the muscular layer and involvement of one of the resected lymph nodes, it was a pT2a N1.
No distant metastases were detected.
Two weeks after the intervention, the patient presented disorientation and a tendency to sleep in the context of a clinical picture compatible with urinary tract infection.
After 24 hours of observation, intravenous hydration and antibiotic therapy were instituted and discharged with oral antibiotics.
Ten days later he returned to the hospital due to dyspraxia, sleep tendency, incoherent language and obnubilation.
During the episode she also had a fever peak of 38.5oC.
Biochemistry and blood count were normal (without leukocytosis or neutrophilia).
Abdominal ultrasound identified moderate bilateral hydronephrosis and a normal brain CT scan.
During admission and after starting broad-spectrum antibiotics and fluid therapy, the confusional state developed and resolved completely.
A few days later, the patient again presented cognitive impairment.
On this occasion, the onset of central symptoms had been similar, with dyspraxia, Glasgow challenge to perform daily tasks, drowsiness and obtundation, but on this occasion he went to the hospital in situation 8.
She was afflicted.
Laboratory tests revealed only moderate hyperglycemia and slight elevation of transaminases.
An electroencephalogram showed slow waves on areas of both hemispheres, characteristic findings of metabolic encephalopathy.
A brain CT scan showed no structural abnormalities.
Similarly to previous admission, after several days hospitalized with supportive fluid therapy and absolute diet, the patient undergoes progressive improvement with complete recovery of the clinic.
Three weeks later, the patient again noticed dyspraxia and progressive sleep onset.
She came to the emergency department where she was evaluated without alterations in the examination or in the analytical or imaging tests, so she was referred to home, there was no fever or any symptoms suggestive of infection.
After 24 hours he presented with a severe alteration of consciousness with a Glasgow score of 6.
At this time, the patient came to the hospital after 15 days had begun, a first cycle of adjuvant chemotherapy with a taxol 175 mg/m2 scheme and plateau AUC 5.
Therefore, the patient had leukopenia with neutropenia attributable to post-chemotherapy myelotoxicity.
All other electrolyte parameters, including calcemia, were strictly normal.
Venous gas showed pH 7.44.
Brain CT and chest X-ray were normal.
The presence of repeated episodes of confusional syndrome of probable metabolic cause, all of them within 3 months of cystectomy, was considered to be a metabolic complication of the shunt.
After ruling out the presence of metabolic acidosis, it was decided to request a blood clotting level, which showed an ammonia level of 400 micrograms/dl (normal between 17-80).
The diagnosis of hyperammonal encephalopathy of non-hepatic cause was initiated fluid therapy, absolute diet, enemas with lactulose and, given the clinical severity, hemodialysis was initiated.
After 3 sessions of hemodialysis, the patient experienced neurological recovery parallel to the correction of the levels of consolidation that decreased until normalization.
Subsequently, a surgical conversion of the sigmoid colon to the ileum was performed.
Currently the patient continues with adjuvant chemotherapy and has not presented new confusional episodes.