Hyperammonemic encephalopathy (HE) refers to a clinical condition characterized by abrupt alteration in mental status (AMS) with markedly elevated plasma ammonia levels and frequently results in intractable coma and death. While hepatic cirrhosis is by far the most common etiology for hyperammonemia together with drugs such as valproic acid as well as urea cycle disorders, non-hepatic causes of hyperammonemia are rare and pose a clinical challenge. In this report, we describe a case of HE caused by obstructive urinary tract infection due to urease-producing bacteria in a 69-year-old man with two episodes of obstructive uropathy associated with AMS resolving with treatment with antibiotics and lactulose with normalization of ammonia level. We also provide a review of the literature with emphasis on the recognition of this serious entity of HE in the setting of obstructive uropathy to avoid the possible complications that include intractable coma and high mortality from this potentially treatable disorder.

There are a significant number of colonoscopies and esophagogastroduodenoscopies (EGDs) done in the United States every year and post-endoscopic infections are frequently seen. Data demonstrating causality between endoscopic procedures and infectious endocarditis (IE) or that antibiotic prophylaxis prior to endoscopic procedures protects against IE is still lacking. Here we have presented the case of a patient who underwent diagnostic colonoscopy as part of a malignancy workup and was later found to be septic with Staphylococcus lugdunensis bacteremia and had IE. We hypothesized that the infection was most likely contracted during colonoscopy as a result of bacterial translocation from the perineal region to the bloodstream. This case report highlights the need for further studies investigating the efficacy of prophylactic antibiotics in reducing the risk of IE after colonoscopies.

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