A 54-year-old male with a history of obesity and type 2 diabetes mellitus, diagnosed with Child-Pugh functional cirrhosis, Model for end Stage Liver Disease (MELD) 19 with signs of significant variceal esophageal varices performed in our outpatient services.
The study of conventional liver disease was negative, including absence of embolic habits, viral serology, copper and iron metabolism, immunological study and alpha1-antitrypsin.
A liver biopsy was performed in which we observed a cirrhosis of micronodular predominance and a liver parenchyma with clear cytoplasms, hepatocytes ballooned with hyaline Mallory alcohol macroconidia, frequent degeneration
The patient had a two-month history of progressive bradylalia, mild postural tremor, and occasionally temporospatial disorientation that did not respond to treatment with lactulose.
Neurological examination showed a Folstein minimental test score of 29/30 and a clock test score of 10/10.
The presence of dysarthria with bradylalia, slight postural tremor and more pronounced action on the left side without asterixis, dentate wheel phenomenon and slowness of alternating upper limb movements stood out.
Laboratory findings showed thrombocytopenia of 105,000 platelets/dl, prothrombin activity of 57%, aminotransferase glutamic puruvic acid (GPT) 36 U/l, alkaline phosphatase glutamic acid
The remaining parameters, including thyrotropin (TSH), vitamin B12 and folic acid, were within normal limits.
An electroencephalogram showed diffuse slowing of brain activity (6 cycles per second), without seizures or associated paroxysmal activity.
Cerebral computed tomography showed leukoaraiosis while magnetic resonance imaging (MRI) revealed hyperintense lesions in T1 and T2 sequences in the basal ganglia and the peduncles.
Due to symptoms and imaging tests, he was diagnosed with chronic hepatocerebral syndrome.
Treatment with lactulose and paramomycin was initiated, but despite presenting an initial improvement, this was followed by progressive cognitive impairment in the following months, so it was programmed for the best therapeutic option in cases of liver failure.
