Sodium Valproate-induced Hyperammonemic Encephalopathy:a Case Report And Literature Review

Background and purposeLong-term use of sodium valproate(also known as Depakotein Depakene,et al.)increases blood ammonia.Hyperammonemia may be common in clinical practice,but it may lead to Valproate-induced hyperammonemic encephalopathy(VHE),which is rare and critical.It is easy to be missed or misdiagnosed as deterioration of mental symptoms or non-convulsive epileptic seizures.The clinical characteristics of VHE are varied.Nonspecific gastrointestinal reaction symptoms often occur in the early stage of the disease,and the progression of the disease can be manifested as the state of consciousness.The frequency of epileptic seizures increases or new types of epileptic seizure,agitated,irritable,cognitive disorders,personality and behavior abnormalities,ataxia,sensory abnormalities,and other focal neurological dysfunction symptoms.It is a clinical emergency,If the intervention is not recognized in time,it can lead to a life-threatening coma.At present,most of the cases are reported,and the exact incidence rate is not clear.There are many VHE studies on the patients with mental illness at home and abroad,but there are less research on the occurrence of VHE in patients in neurology department.This may be related to the rare case of VHE caused by single drug treatment of VPA..This article analyzes the use of sodium valproate to prevent epilepsy induced by epilepsy after cranioplasty in our hospital,which resulted in VHE cases,and combines relevant literature analysis to improve clinical understanding of VHE.MethodThe clinical data of a case of VHE with VHE treated with valproate after cranioplasty were analyzed retrospectively,including clinical manifestation,laboratory examination,imaging examination,analyse the reason of disturbance of consciousness delirium and misdiagnosis analysis.and the epidemiology,risk factors,diagnosis and differential diagnosis,causes of misdiagnosis,treatment and prognosis of the disease were also discussed.Using the key words "valproic acid,hyperammonemia,encephalopathy,Valproate-induced hyperammonemicencephalopathy,altered mental status ",we manually searched CNKI,Wanfang Medline,Pubmed and other domestic and foreign databases about VHE patients in Psychiatology and Neurology with complete data and analysis from 2008 to April2018.Results1.A case of hyperammonia encephalopathy caused by sodium valproate misdiagnosed as hysteria in our hospital was reported.The results suggest that VHE is a rare and serious adverse reaction in the treatment of VPA,which is easy to misdiagnose.2.From 2008 to April 2018,the literature on VHE patients in domestic and foreign databases was searched.It was found that there were few reports of complete case data,and most of them were case reports.Two of them reported the same patient’s case data,the other two reported the case data of 4 patients in detail respectively,so they were included in the study.The number of target documents in Chinese medical literature was 8.One of them reported 2 patients.A total of 35 articles were included,and one case was reported in this paper,42 patients.The age,sex,duration of VPA dose,blood ammonia level,whether to increase the dose(misdiagnosed),clinical symptoms,etc in all patients were analyzed.5 patients as VHE clinical symptoms still increase or maintain the VPA dose.The level of blood ammonia in VHE patients was often elevated,and the clinical symptoms of all patients were fully recovered after the VPA decrement or withdrawal.3.SPSS17.0 statistical software was used to analyze related variables,and VPA level was significantly correlated with VPA duration(P=0.001).The level of blood ammonia was related to multidrug therapy(P=0.045),and the level of VPA was related to a variety of drug treatments(P=0.026),and misdiagnosis was associated with multiple drug treatments(P=0.04).Conclusion1.The use of the antiepileptic drug sodium valproate in neurology and psychiatry led to VHE.If the drug was misjudged to be a recurrent epilepsy or hysteria,and antiepileptic drugs increased quantity or sedative drug use,will further aggravate the brain damage.Therefore,the concentration of antiepileptic drugsshould be closely monitored in clinic,the serum ammonia level should be checked in time for the patients with mental state change,and the discontinuation of VPA is the main treatment plan of VHE at present.2.VPA level and blood ammonia level were correlated with multidrug therapy,while blood ammonia level was not correlated with VPA level,misdiagnosis and clinical symptoms.