Valproate-induced hyperammonemic encephalopathy: a case report.

BACKGROUND: Hyperammonemic encephalopathy is a rare and serious adverse reaction to valproate. Although there is documentation of this reaction in previous reports, very little is still known about the exact mechanism of action. In addition, there are no established guidelines of the next steps needed when a patient does develop this reaction. Therefore, this case report highlights what is known as well as the areas of research still needed. CASE PRESENTATION: Our patient was a 57-year-old Caucasian woman with a medical history of bipolar I disorder, opioid use disorder, benzodiazepine use disorder, and Crohn's disease who was admitted to our behavioral health unit for suicidal ideation. She had been experiencing multiple panic attacks for 2.5 weeks along with poor sleep, increased energy, excessive spending, and feelings of helplessness. The patient was diagnosed with bipolar I disorder, manic episode without psychotic features, and benzodiazepine use disorder. She was started on valproic acid, citalopram, propranolol, and quetiapine. By day 6 of her hospitalization, the patient had altered mental status, varying levels of consciousness, confusion, and ataxic gait. Her ammonia levels were found to be elevated. All of her medications were discontinued, and lactulose was initiated. She returned to her baseline mentation within 48 hours and was discharged with lithium and quetiapine. The treatment team concluded that this patient had valproate-induced hyperammonemic encephalopathy, a rare but reversible reaction to valproate. CONCLUSION: Fortunately, rapid identification of this rare condition led to a favorable outcome in our patient. This case report illustrates the course of treatment in a patient who experienced this reaction and reviews current knowledge as well as areas of needed research in regard to valproate-induced hyperammonemic encephalopathy.

The Forgotten Plague: Psychiatric Manifestations of Ebola, Zika, and Emerging Infectious Diseases.

The media and public health generally focus on the biological and physical ramifications of epidemics. Mental health issues that coincide with emerging diseases and epidemics are rarely examined and sometimes, even eschewed due to cultural considerations. Psychiatric manifestations of various infectious diseases, especially with a focus on Ebola Virus disease (EVD) and Zika Virus, are discussed in this commentary to illustrate the continued need of care after the resolution of the actual illness. Various infectious diseases have associations with mental illness, such as an increased risk of obsessive-compulsive disorders and Tourette syndrome in children with Group B streptococcal infection. Current EVD literature does not demonstrate a strong association of mental illness symptoms or diseases but there is a necessity of care that extends beyond the illness. Patients and their families experience depression, anxiety, trauma, suicidal ideation, panic and other manifestations. Zika virus has been associated neuronal injury, genetic alteration that affects fetal development and detrimental maternal mental health symptoms are being documented. While funding calls from the international community are present, there are no specific epidemiological data or fiscal estimates solely for mental health during or after infectious diseases epidemics or disasters that support health care providers and strengthen policies and procedures for responding to such situations. Therefore, those on the frontlines of epidemics including emergency physicians, primary care providers and infectious disease specialists should serve communicate this need and advocate for sustained and increased funding for mental health programs to heighten public awareness regarding acute psychiatric events during infectious diseases outbreaks and offer treatment and support when necessary.