Acquired hepatocerebral degeneration revealed by neurogenic hyperventilation syndrome and myelitis

A 46-year-old woman with a history of kidney transplant for IgA nephropathy (on tacrolimus and mycophenolate mofetil), type II diabetes and non-alcoholic steatohepatitis was admitted for gait instability. Neurological examination revealed lower limb sensory ataxia and brisk patellar reflexes. Brain/spinal MRI results were normal. Blood tests disclosed macrocytosis (but no vitamin deficiencies) and mild hepatic cytolysis. Lumbar puncture showed the absence of cells, normal protein, hypoglycorrhachia (glycorrhachia: 0.62 g/l; glycaemia: 1.65 g/l) and no oligoclonal bands. Cerebrospinal fluid cultures were negative. Assays for neurotropic viruses, paraneoplastic …