Acute Severe Pancreatitis: A Dreadful Complication of Sodium Valproate

Excerpt

To the Editor: Acute pancreatitis is a rare diagnosis in pediatrics. Valproic acid has been known to trigger this catastrophe in occasional young patients as an idiosyncratic reaction [1]. We describe a typically developing eight-year-old boy who presented to emergency department with acute abdomen (severe, diffuse non-radiating abdominal pain with non-bilious vomiting) and fever for 48 h. He was on oral valproate (30 mg/kg/d), phenobarbitone (3 mg/kg/d) and clonazepam (0.04 mg/kg/d) for his underlying epilepsy. He was diagnosed with super-refractory status epilepticus of unknown etiology nine months back and has been receiving antiepileptics since then. There was not any history of recent change in antiepileptic dosages. On examination, there was tachycardia (pulse rate = 120/min), tachypnea (respiratory rate = 38/min), diffuse abdominal tenderness and guarding. His hemogram revealed leukocytosis (12,760/cumm with 60% neutrophils) and low platelet count (118,000/cumm). Ultrasound abdomen and chest revealed mild ascites and bilateral minimal pleural effusion with non-visualization of pancreas. A working diagnosis of valproate induced acute pancreatitis was considered. Raised serum amylase (647 SU, normal = 28–100 SU) and serum lipase (514 SU, normal = 0–190 U/L) confirmed the presence of pancreatitis. Serum Valproic acid (VPA) level was within therapeutic range (56.68 mcg/ml, normal = 50–100 mcg/ml). Work up for infective etiology (dengue, rickettsia, chikungunya, coxsackie, cytomegalovirus) was negative. Child was made nil-per-oral and started on intravenous hydration with antibiotics (piperacillin tazobactam and metrogyl), proton pump inhibitors and opioids for pain relief. VPA was immediately stopped and replaced with levetiracetam. On day 2 of hospitalization he developed hypoxia with increased pleural effusion, ascites and loose stools which responded to conservative management within 48–72 h. Child did not have any neurological issues during the stay and was discharged after 1 wk. Amylase levels got normalized (0.5 SU). …