title: Acute hyperammonemic coma with chronic valproic acid therapy.
abstract: OBJECTIVE
  To report a case of dose-related hyperammonemic coma without liver failure in a patient receiving chronic valproate therapy.
  
  
  METHODS
  A 56-year-old woman with poorly controlled epilepsy, receiving valproate at subtherapeutic levels for 6 years, developed a life-threatening hyperammonemic coma following a moderate dosage increase.
  
  
  CONCLUSIONS
  Hyperammonemic coma without associated liver failure is an extremely rare complication of valproate therapy, described primarily in patients with inborn errors of metabolism and occurring idiosyncratically during initial stages of therapy. In our case, family history was suggestive of an X-linked disorder, raising the possibility that our patient may have been an asymptomatic carrier of a urea cycle enzyme deficiency unmasked by valproate therapy. To our knowledge, as of October 24, 2005, only one prior case of hyperammonemic coma in the context of chronic valproate monotherapy has been described. Application of the Naranjo probability scale score suggests that a causal relationship between valproic acid and hyperammonemic coma was probable.
  
  
  CONCLUSIONS
  The widespread use of valproic acid emphasizes the need to maintain a high degree of suspicion with respect to this rare but potentially fatal adverse effect at all times, regardless of therapy duration.
authors.affiliation: Division of Neurology, Department of Neuropsychiatry and Behavioral Science, School of Medicine, University of South Carolina, Columbia, 29203, USA. mirocuturic@yahoo.com
authors.forename: Miroslav
authors.initials: M
authors.lastname: Cuturic
authors.forename: Ruth K
authors.initials: RK
authors.lastname: Abramson
mesh_terms: D000927:Anticonvulsants / Q000009:adverse effects* / Q000627:therapeutic use; D003128:Coma / Q000139:chemically induced* / Q000150:complications / Q000235:genetics; D004569:Electroencephalography; D004827:Epilepsy / Q000150:complications / Q000188:drug therapy / Q000235:genetics; D005260:Female; D006801:Humans; D022124:Hyperammonemia / Q000139:chemically induced* / Q000150:complications; D008875:Middle Aged; D010375:Pedigree; D014635:Valproic Acid / Q000009:adverse effects* / Q000627:therapeutic use
chemical_list: D000927:Anticonvulsants; D014635:Valproic Acid