Not all that trembles…: a rare case of extrapyramidal impairment.

An hypertensive and hypercholesterolemic 80-year-old man, with a previous history of peptic ulcer and non-melanoma skin cancer, currently in stable class B Child–Pugh liver cirrhosis (LC) secondary to chronic hepatitis B virus (HBV) infection, was admitted to our emergency department (ED) because of progressive dysarthria and disequilibrium. At admission in the ED, emodynamic was stable (arterial pressure was 110/96 mmHg and heart rate 63 bpm), he was non febrile and alert. The neurological examination was consistent with only mild dysarthria with no lateral deficits and no flapping tremor. Pharmacological history included prazole, carvedilol, atorvastatin, potassium canrenoate, furosemide, lactulose, and entecavir. The recent anamnesis was positive for a hospitalization due to acute hepatic encephalopathy (HE) successfully managed with cathartics, but negative for gastrointestinal bleeding or alteration of the alvus, despite a still high ammonium concentration (156 umol/L). Other laboratory findings were related to mild hepatic failure and portal hypertension (INR 1.72, PLT 66,000/mmc, total bilirubin 1.78 mg/dL, and albumin 2.2 g/dL), in absence of serum electrolyte disorders and any signs of inflammation (WBC 4000/mmc, RCP 0.22 mg/dL). Resting standard 12-lead electrocardiogram (EKG) showed sinus rhythm. First head computed tomography (CT) scan without contrast excluded acute ischemic hypodense lesions, acute or chronic haemorrhagic foci and signs of intracranial hypertension. A definitive diagnosis for the acute neurologic impairment could not be reached, so the patient was admitted to our Internal Medicine department for further investigations