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...