Diagnostic Dilemma: Incidental Diagnosis of Decompensated Liver Cirrhosis during Evaluation of Unexplained Neurological Decline in an Elderly Patient: A Case Report

Background: Neurological deterioration in older adults is frequently correlated to cerebrovascular disease, spinal pathology, or age-related neurodegenerative processes. However, such presentations are multifactorial, and systemic illnesses should be considered part of the differential diagnosis that contribute significantly to cognitive and functional decline. Case Presentation: A 69-year-old man who presented with progressive confusion, gait instability, recurrent falls, and functional deterioration following a fall, neurological examination was done a distinct sensory deficit below the T5 - T6 dermatomal level was incidentally noted during an abdominal examination, Initial neurological evaluation was initiated, including brain and spinal imaging, which revealed chronic microangiopathic changes, cervical spinal stenosis, a T12 compression fracture, and a possible lacunar infarct. However, these findings were insufficient to explain the severity of his cognitive impairment, raising concern for a clinicoradiological mismatch. Further evaluation included abdominal CT, which revealed a large-volume ascites and features of chronic liver disease. Diagnostic paracentesis was performed and demonstrated portal hypertensive ascites with a serum-ascites albumin gradient (SAAG) greater than 1.1 g/dL. Laboratory investigations showed hypoalbuminemia, prolonged coagulation, elevated liver enzymes, and increased serum ammonia levels. The patient was diagnosed with decompensated alcohol-related liver cirrhosis (Child-Pugh Class C) complicated by hepatic encephalopathy. Treatment with lactulose, rifaximin, spironolactone, and carvedilol was initiated, and clinical improvement was noted; the patient was subsequently transferred back to the rehabilitation department for ongoing care. Conclusion: This case demonstrates the importance of maintaining a broad differential diagnosis when imaging findings do not fully explain neurological symptom, that unexplained neurological deterioration in older adult may be the first manifestation of an underlying systemic illness. Recognition of clinicoradiological discordance may uncover systemic diseases with major implications for management, rehabilitation, and prognosis.