Abstract
We report a case of a patient who had been on long time valproic acid for treatment of bipolar affective disorder. While being an inpatient, serology ammonia level testing revealed a very high ammonia level despite being asymptomatic. Dual therapy of carnitine and lactulose was provided to the patient for treatment of the hyperammonemia. It should also be noted that, during this treatment, valproic acid was not stopped. Consequently, this case illustrates that patients can present asymptomatically despite very high ammonia levels and hyperammonemia can occur in chronic valproic acid despite not increasing the dose of the medication and psychiatrists do not need to discontinue valproic acid in the presence of elevated levels of ammonia if the patient shows no signs of encephalopathy or delirium.
Highlights
Valproic Acid (VPA) is a commonly used psychiatric drug for several disorders and is primarily used as a mood stabilizer and can be combined with antipsychotics
There is evidence that these symptoms of VPA toxicity are secondary to the accumulation of VPA metabolites and increased levels of ammonia, hyperammonemia [1]
Literature shows that high ammonia levels are elevated in 20% to 50% of patients prescribed VPA [5]
Summary
Valproic Acid (VPA) is a commonly used psychiatric drug for several disorders and is primarily used as a mood stabilizer and can be combined with antipsychotics. Clinicians of all fields should be aware that toxicity of VPA can present clinically with lethargy, vomiting, and focal neurologic deficits as well as varying levels of consciousness, including coma in extreme cases [1]. As a result, it is important for physicians who prescribe VPA to their patients to closely monitor VPA level in both an outpatient and inpatient setting. We report a unique case of an asymptomatic presentation of a very high ammonia level (225 μmol/L) in an adult patient that has been on chronic VPA treatment for bipolar affective disorder. Our study aimed to contribute to the literature and educate physicians in clinical practice with regard to management of hyperammonemia secondary to VPA therapy
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