title: Normoammonemic encephalopathy: solely valproate induced or multiple mechanisms?
abstract: A 77-year-old woman presented with subacute onset progressive confusion, aggression, auditory hallucinations and delusions. In the preceding months, the patient had a number of admissions with transient unilateral hemiparesis with facial droop, and had been started on valproate for presumed hemiplegic migraine. Valproate was withdrawn soon after admission and her cognitive abilities have gradually improved over 3 months of follow-up. Valproate levels taken prior to withdrawal were subtherapeutic and the patient was normoammonaemic. EEG undertaken during inpatient stay showed changes consistent with encephalopathy, and low titre N-methyl-D-aspartate (NMDA) receptor antibodies were present in this patient. The possible aetiologies of valproate-induced encephalopathy and NMDA receptor-associated encephalitis present a diagnostic dilemma. We present a putative combinatorial hypothesis to explain this patient's symptoms.
authors.affiliation: Cambridge University, Cambridge, UK.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Budhdeo
authors.forename: Malcolm
authors.initials: M
authors.lastname: Marquette
authors.forename: Deepwant
authors.initials: D
authors.lastname: Singh
authors.forename: Vivek
authors.initials: V
authors.lastname: Rajagopal
mesh_terms: D000368:Aged; D000374:Aggression; D060426:Anti-N-Methyl-D-Aspartate Receptor Encephalitis / Q000150:complications* / Q000276:immunology; D001927:Brain Diseases / Q000209:etiology*; D003221:Confusion / Q000209:etiology*; D003702:Delusions / Q000209:etiology*; D005260:Female; D018682:GABA Agents / Q000009:adverse effects*; D006212:Hallucinations / Q000209:etiology*; D006801:Humans; D020325:Migraine with Aura / Q000188:drug therapy*; D014635:Valproic Acid / Q000009:adverse effects*
chemical_list: D018682:GABA Agents; D014635:Valproic Acid