Hyperammonemic Induced Coma by Bacterial Overgrowth in a Child With Hirschsprung's Disease

Cases with Hirschsprung's disease show the functional intestinal obstruction. Obstruction in these patients may lead to bacterial overgrowth with stasis and inflammation of the colon. Bacterial overgrowth can cause hyperammonemia that makes lethargy and loss of conscious and finally admitting in ICU. The purpose of this case report is to present a case that had Hirschsprung's disease and referred to Children's Medical Center with serum hyper-ammonium caused by bacterial overgrowth that induced coma and altered level of consciousness then made her to admit to PICU. A 15-year-old female referred to Children's Medical Center with lethargy and low grade diarrhea. She had hypocalcemia and hypoalbuminemia with high PT and INR. Because of loss of conscious, she admitted at PICU. Laboratory findings showed hyperammonemia in this case, but other criteria were normal. Administration of antibiotic and lactulose therapy was started that lead to a reduction in serum ammonium level and discharging of the case. Thirteen days later she referred again with mentioned symptoms, and clinical evaluations showed high serum ammonium level. This time because of loss of conscious she had to admit at PICU and used NG tube. Administration of lactulose syrup and sodium benzoate make her in a better condition. Narrowing rectum toward the sigmoid and highly enlarged intestinal lopes was on behalf of Hirschsprung's disease. Finally, the patient with the acceptable situation and oral periodic metronidazole discharged. It is essential to check serum ammonium level in the cases with loss of conscious. The choice for controlling hyperammonemia is lactulose therapy.