Mithani Farhan, Cullum Stav, Chacko Ranjit
College of Medicine, Texas A&M Health Science CenterBryanTexas.
Department of Psychiatry, Houston Methodist HospitalHoustonTexas.
Proc (Bayl Univ Med Cent). 2020 May 21;33(3):471-472. doi: 10.1080/08998280.2020.1767460. eCollection 2020 Jul.
A 24-year-old man with a past medical history of behavioral disturbances and spastic tetraplegia secondary to traumatic brain injury presented to the psychiatry consult service with acute exacerbation of agitation and aggression. The patient's behavioral disturbances were previously reduced with 1500 mg daily of valproic acid (VPA). Prior to admission, VPA was discontinued due to elevated serum ammonia levels of 96 μmol/L and clinical findings consistent with valproate-induced hyperammonemic encephalopathy (VIHE), such as lethargy, confusion, frank delirium, and ataxia. Current guidelines for treating VIHE suggest either a complete discontinuation of the drug or a drug rechallenge with the addition of levocarnitine or carglumic acid supplementation. In this case, VPA was rechallenged without supplementation to decrease the risk of noncompliance. The patient received a lower dose of VPA with subsequent up-titration. His ammonia level decreased to an acceptable level. This case report discusses the challenges of managing VIHE in patients requiring VPA and discusses opportunities for further research in preventing VIHE.
一名24岁男性，既往有创伤性脑损伤继发行为障碍和痉挛性四肢瘫病史，因激越和攻击行为急性加重就诊于精神科会诊服务。该患者的行为障碍此前通过每日1500毫克丙戊酸（VPA）得到缓解。入院前，由于血清氨水平升高至96微摩尔/升，且有与丙戊酸盐诱导的高氨血症性脑病（VIHE）相符的临床表现，如嗜睡、意识模糊、明显谵妄和共济失调，停用了VPA。目前治疗VIHE的指南建议要么完全停用该药物，要么在补充左卡尼汀或卡谷氨酸的情况下重新使用该药物。在本病例中，为降低不依从风险，在未补充药物的情况下重新使用了VPA。患者接受了较低剂量的VPA，随后进行了滴定。他的氨水平降至可接受水平。本病例报告讨论了在需要VPA的患者中管理VIHE的挑战，并讨论了预防VIHE的进一步研究机会。
