Differential diagnosis in case of overdose of antiepileptic treatment. Clinical case

Abstract

Acute drug-related acute intoxications or suicidal ideation following overdose with anticonvulsants may cause major morbidity, in many cases requiring intensive care and prolonged periods of hospitalization. The case of a 35-year-old patient known for a history of epilepsy with phenobarbital and carbamazepine treatment is brought to the Emergency Unit by transfer from another hospital in a comatose state with insufficient respiratory performance, bilateral active mydriasis. From the family members' claims, the patient discontinued treatment with phenobarbital two weeks ago. Following interdisciplinary examination, hospitalization in the Neurology Department with the diagnosis of epileptic status is decided. Due to the progressive aggravation of acute respiratory insufficiency, the ventilator support is constituted. Since the biological samples related to probability diagnosis and cerebral imaging were not conclusive, toxicological samples were collected. The GC/MS analytical toxicology screening in urine reveals the presence of carbamazepine and phenobarbital and their plasma levels (5.92 and 92.3 mg/l) as determined by the FPIA method indicate an overdose of phenobarbital therapy. The patient is taken over by the Department of Clinical Toxicology where specific intensive care measures are applied. Clinical evolution is favorable. The psychiatric examination highlights the depressive idea, suicidal ideas, and uselessness. The suicide attempt is confirmed. It also presents a review of the main information about acute poisoning with anticonvulsants, but also about the analytical laboratory methods that bring precious information in establishing the diagnosis of certainty.