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Hyperammonaemia is often seen in the context of decompensated liver disease. It may also be triggered by stressful medical conditions in adults with partial enzyme deficiencies of the urea cycle. Occasionally, non-hepatic causes can result in hyperammonaemia severe enough to cause symptoms. The authors report the case of a 52-year-old Turkish woman who presented with acute-on-chronic confusion, drowsiness and lethargy. Laboratory investigations revealed hyperammonaemia which had an unclear cause. Although first thought to be secondary to a concurrent urinary tract infection, the high serum ammonia was eventually attributed to her carbamazepine. The authors recommend that doctors should include urinary tract infection and iatrogenic causes in their differential diagnosis in patients with hyperammonaemia and neurological symptoms, especially when this may be misleading in the diagnostic process.

Transient hyperammonaemia in a patient with confusion: challenges with the differential diagnosis