Hepatic encephalopathy presenting as delirium and mania. The possible role of bilirubin

The case of a woman who suffered from hepatic encephalopathy is described. The psychiatric symptoms presented first as a delirium, changing into a manic syndrome. As the neurotoxic direct fraction of bilirubin was greater than 100 times normal, increasing and decreasing in a parallel fashion with the psychiatric symptoms, direct bilirubin is assumed to play a role in the pathogenesis of this case. This is discussed in the context of bilirubin encephalopathy, very seldom diagnosed in adults.