Hyperammonemic Encephalopathy due to Valproic Acid and Topiramate Interaction

Twilla, Jennifer D.; Pierce, Andrew

doi:10.1155/2014/410403

Cited by 14 publications

(15 citation statements)

References 15 publications

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“…Our case differed from others as valproate induced hyperammonemia did not progress to encephalopathy (seizure, focal neurological deficit, coma or death) [7,[9][10][11]. Secondly valproate induced hyperammonemia developed while on monotherapy with valproate and there was neither polypharmacy [8] nor known medical comorbidity [8,9]. Lastly stoppage of divalproex sodium for few days lead to prompt recovery and no other treatment measure like carnitine, lactulose, heamodylysis [12,13] were required.…”

Section: Discussionmentioning

confidence: 67%

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Valproate Induced Delirium due to Hyperammonemia in a Case of Acute Mania: A Diagnostic Dilemma

Dixit¹

2015

JCDR

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A 31-year-old male with no past history of any significant medical illness manifested with acute onset of behavioural problems of seven-eight days duration in form of increased psychomotor activity, elated mood, verbosity, distractibility, enhanced self esteem, hyper-religiosity, delusion of grandiosity, impaired biodrives (sleep, appetite and libido) in absence of any perceptual disturbance and with intact sensorium. There was no history of fever, altered sensorium, neurological deficit and significant weight loss prior to onset of behavioural abnormalities. There were no developmental issues. Physical examination revealed pulse 82/min, BP 130/82 mm of Hg, afebrile, respiratory rate was 16/min, no digital tremors or hyperhydrosis. Lab investigations including heamogram, LFT, urea, creatinine, blood sugar, lipid profile, serum electrolyte, X-ray chest, CT Scan Brain, T3, T4, and TSH was within normal limits and HIV status was negative. He was diagnosed as a case of mania with psychotic symptoms as per International Classification of Diseases 10 (ICD10) [1] and started on mood-stabilizer tab divalproex sodium 500 mg BD and olanzapine 5 mg BD. Patient started showing improvement. By 10 th day his symptoms remitted to about 40% however his hyper-religiosity, self esteem and grandiose manners though less severe persisted, however on 13 th day patient complained of headache right hemi-cranium lasting for half hour to one hour accompanied by nausea and vomiting. His pulse, BP and temp were normal. MRI brain and fundoscopy revealed no abnormality. A neurophysician referral resulted in prescription of tab topiamate 25 mg BD in view of vascular headache and the same evening (15 th day of admission) after receiving tab topiramate patient developed disorientation, confusion, unsteadiness of gait, irrelevant talks and agitation which continued for next three-five days. His topiramate was stopped immediately. His MMSE score was 13/30. Subsequently divalproex sodium was increased to 1500 mg along with 15 mg of olanzapine by 22 nd day. EEG revealed normal bilateral symmetrical 9-12 Hz posteriorly dominant alfa rhythms. Patient did not show any improvement and continued to remain puzzled, dazed, confused and disoriented during day time with irrelevant talk and exhibited more hyperactivity towards evening with altered sleep-Wake schedule. His physical examination revealed pulse 88/min, BP 136/88 mm of Hg, respiratory rate 18/ min. There were no menningeal, cerebellar or extra pyramidal signs. keywords: Bipolar disorder, Encephalopathy, Non hepatic hyperammonemia, Valproic acidHis neurological examination was non contributory. His repeat liver function, electrolyte, urea, creatinine and CPK levels were within normal range. A pre-anesthetic check up was done and after taking appropriate consent of patient and relatives, he was taken up for electroconvulsive therapy (ECT) on 29 th day suspecting it to be a case of Delirious mania. ECT was planned twice a week. Before starting ECT dose of divalproex sodium was reduced to 250 mg BD t...

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Section: Discussionmentioning

confidence: 67%

“…VIHE was first reported from psychiatric side in 1995 [7] and uptill now about 36 cases of VIHE have been reported from psychiatric arena [8]. Our case differed from others as valproate induced hyperammonemia did not progress to encephalopathy (seizure, focal neurological deficit, coma or death) [7,[9][10][11].…”

Section: Discussionmentioning

confidence: 73%

Valproate Induced Delirium due to Hyperammonemia in a Case of Acute Mania: A Diagnostic Dilemma

Dixit¹

2015

JCDR

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“…Çoklu ilaç kullanýmýnýn hiperamonyemi oluþumunda risk oluþturduðu bilinmektedir (6). Bizim olgu-muzda hasta VPA yaný sýra zuklopentiksol ve olanzapin kullanmýþtýr.…”

Section: Gýrýþunclassified

Valproic acid induced hyperammonemic encephalopathy: A case report (Turkish)

Apa¹,

Ateşçi²,

Varma³

2018

J Clin Psy

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Valproic acid (VPA) is commonly used drug to treat variety of anticonvulsant and mood stabilizer in psychiatric and neurologic cases. It is thought to be a safe drug with a large therapeutic aspect..Uncommonly, hyperammonemia can be progressed by the usage of valproate and VPA induced hyperammonemia delirium-like condition by extrahepatic origin can be constituted. Being unrecognized of this situation in a timely manner can result in encephalopathy and even death. The measurement of the level of ammonia is important to establish a potentially lethal but reversible situation. In this case study, it is aimed that to present hyperammonemia related to the use of psychotropic drugs and to present a patient with hyperammonemia during VPA and antipsychotic use without a medical disease except bipolar disorder in the past.

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“…Twilla ve Pierce (2014), VPA ve topiramat birlikte kullanýmý sýrasýnda geliþen amonyak yüksekliði belirlenen bir olguyu sunmuþlar ve çoklu ilaç kullanýmýnýn bu riski arttýrdýðýna dikkat çekmiþlerdir. Bu yayýnda psikiyatri alanýndan bildirilmiþ yaklaþýk 36 olgu olduðu belirtilmiþtir (6). Olgu sunumlarýnda, psikotik özellikli bipolar bozukluk tanýsý ile VPA kullanýlan bir hastada 3 kez hiperamonyemiye baðlanan hipoaktif deliryum (7); 11 yýldýr VPA tedavisi alan bir hastada akut hiperamonyemi ve deliryum (8) ve serum VPA düzeyi normal sýnýrlar-dayken hiperamonyemik ensefalopati geliþtiði (9) bildirilmiþtir.…”

Section: Tartiþmaunclassified

“…Çoklu ilaç kullanýmýnýn hiperamonyemi oluþumun-da risk oluþturduðu bilinmektedir (6). Bizim olgu-muzda hasta VPA yaný sýra zuklopentiksol ve olanzapin kullanmýþtýr.…”

Section: Tartiþmaunclassified

Valproic acid induced hyperammonemic encephalopathy: A case report (Turkish)

Apa¹,

Ateşçi²,

Varma³

2018

J Clin Psy

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SUMMARYValproic acid (VPA) is commonly used drug to treat variety of anticonvulsant and mood stabilizer in psychiatric and neurologic cases. It is thought to be a safe drug with a large therapeutic aspect..Uncommonly, hyperammonemia can be progressed by the usage of valproate and VPA induced hyperammonemia delirium-like condition by extrahepatic origin can be constituted. Being unrecognized of this situation in a timely manner can result in encephalopathy and even death. The measurement of the level of ammonia is important to establish a potentially lethal but reversible situation. In this case study, it is aimed that to present hyperammonemia related to the use of psychotropic drugs and to present a patient with hyperammonemia during VPA and antipsychotic use without a medical disease except bipolar disorder in the past.

show abstract

Hyperammonemic Encephalopathy due to Valproic Acid and Topiramate Interaction

Cited by 14 publications

References 15 publications

Valproate Induced Delirium due to Hyperammonemia in a Case of Acute Mania: A Diagnostic Dilemma

Valproate Induced Delirium due to Hyperammonemia in a Case of Acute Mania: A Diagnostic Dilemma

Valproic acid induced hyperammonemic encephalopathy: A case report (Turkish)

Valproic acid induced hyperammonemic encephalopathy: A case report (Turkish)

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