Portosystemic myelopathy: a rare neurological presentation of portosystemic shunts

Portosystemic myelopathy is an unusual complication in patients with chronic liver disease with hepatic encephalopathy and portosystemic shunts. Here we present a case of 35-year-old male patient who presented to us with difficulty in walking and progressive stiffness in both lower limbs for two months. He had undergone splenectomy with distal splenorenal shunt 20 years back. On physical examination, he had spasticity in both lower limbs of grade 3, with minimal pyramidal weakness in lower limbs, brisk knee and ankle jerks. The plantar response was extensor. Upper limb examination was normal. On investigations, he had hypoalbuminemia, hyperbilirubinemia, increased plasma ammonia levels. Contrast enhanced CT scan abdomen revealed dilated splenorenal shunt and MRI spine showed no spinal cord compression. Electromyoneurogram was also normal. Spastic paraparesis due to portosystemic shunts was diagnosed. Liver transplantation can reverse the myelopathy only in earlier stages, hence early and accurate diagnosis is important.