Hyperammonemic Encephalopathy in Multiple Myeloma: A Case Report

Abstract

Multiple myeloma (MM) typically presents as lytic bony lesions, hypercalcemia, anemia, and renal failure. Only a few cases of hyperammonemic encephalopathy (HE) attributed to multiple myeloma have been reported. We report a case of a 68-year-old Hispanic female diagnosed with multiple myeloma and presented with altered mental status and elevated ammonia levels found to have HE. The pathology behind HE is associated with higher ammonia levels produced by myeloma cell lines in the absence of liver disease. Due to the wide range of differentials for altered mental status (AMS), HE often gets missed and causes delayed treatment and the associated higher mortality. The primary treatment is chemotherapy. Lactulose and rifaximin must be initiated; however, it is ineffective if solely used. In our case, chemotherapy was not considered a treatment option in light of the patient's pancytopenia and infection. Our case is unique, as despite adequately treating other commonly suspected causes of AMS such as infection, there was no expected improvement in the patient's clinical status noticed, eventually leading to intubation due to worsening AMS. Given the patient's history of multiple myeloma, non-compliance with chemotherapy before presentation, and elevated ammonia levels raised suspicion for HE. Clinicians are encouraged to acquaint themselves with HE as a differential for patients presenting with MM flare and AMS, specifically when other potential causes of AMS are ruled out and addressed.

Hyperammonemic Encephalopathy: A Rare Presentation of Relapsed Multiple Myeloma

“…Based on studies published thus far, it is proposed that ammonia is produced and released from myeloma cell lines themselves [ 6 ]. Another theory is that myeloma-related humoral factors influence ammonia acid metabolism, leading to hyperammonemia [ 7 ]. A persistent finding in cases of hyperammonemia due to MM is that lactulose and hemodialysis do not lower ammonium levels, and therefore, the mainstay of treatment is chemotherapy with high-dose cyclophosphamide, bortezomib, and dexamethasone [ 7 - 9 ].…”