High-protein dietary supplements were started for 2 patients, who had a period of anorexia before hospital admission but no history of liver disease. Subsequent altered mental status with ataxia developed in both patients. After excluding other causes, hyperammonemia was noted, while liver function test results remained normal. Removal of the high-protein dietary supplements led to reversal of symptoms and normalization of the ammonia level. With the ubiquity of nutrition supplement use outside of liver failure, SHAKE (supplement-associated hyperammonemia after c[k]achetic episode) syndrome may be commonplace in modern hospitals.
Welsh E, Kucera J, Perloff MD. Iatrogenic Hyperammonemia After Anorexia. Arch Intern Med. 2010;170(5):486-488. doi:10.1001/archinternmed.2009.549