Thanks to the many colleagues that showed interest and
made helpful comments regarding this case. Many of you
have mentioned carnitine depletion during valproate
therapy which may predisposes to its toxicity. This
patient has developed fulminant hepatic
necrosis/failure while on long term valproate. She
also has muscle wasting (secondary to cerebral palsy)
which might have put her at higher risk of carnitine
depletion and valproate toxicity. She has also
developed rhabdomyolysis (CK 101210 IU/L) and acute
renal failure which has been described in valproate
toxicity. Being on long term treatment would n't
exclude an idiosyncratic reaction to valproate which
is the probable mechanism in this sad case. Some of
you have mentioned carnitine supplementation in such
patients on long term valproate therapy to minimise
the risk of toxicity. This case can also be labelled
as Reye's syndrome induced by valproate as fulminant
heptic failure and encephalopathy due to mitochondial
disruption, constitute its main features. I have
learnt a lot from this case.
regards
Mohammad
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Dr. M A Al-Jubouri
Consultant Chemical Pathologist
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