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We report the case of a 51-year-old male patient, who was found in a collapsed state, suffering from respiratory distress. Medical history was of chronic liver disease with portal hypertension due to high alcohol intake and epilepsy. Medications included sodium valproate, gabapentin, omeprazole, thiamine and codeine.
On admission to hospital, he required early intubation and ventilatory support. Initial investigations revealed evidence of community-acquired pneumonia together with poor synthetic liver function and raised serum ammonia levels. He received inotropic support, intravenous antibiotics, lactulose, rifaximin and pabrinex.
By day 7, the patient was showing little progress with failed extubation and continued elevated serum ammonia levels. His family were …
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