Encephalopathy in an infant with infantile spasms: possible role of valproate toxicity.

An infant presented with global developmental delay and infantile spasms. EEG was suggestive of hypsarrhythmia. She was started on sodium valproate, clonazepam and adrenocorticotropic hormone injection. After an initial improvement the child developed vomiting, altered sensorium and increase in frequency of seizures suggestive of encephalopathy. Valproate-induced hyperammonaemia or hepatic encephalopathy was considered and the drug was withheld following which there was a dramatic improvement. Paradoxically, the liver function tests and serum ammonia were normal. However, a complete reversal of encephalopathy, on withdrawal of the drug, strongly suggested an adverse drug reaction (ADR) due to valproic acid. Marginal elevation of serum valproic acid prompted us to use the Naranjo ADR probability score to confirm the diagnosis. This case highlights the fact that valproate toxicity can manifest with normal liver function and serum ammonia levels. This is the youngest reported case with this rare form of valproate-induced encephalopathy.

Massive consolidation: a rare manifestation of paediatric Scrub typhus.

Despite resurgence in the number of Scrub typhus cases, it still poses a diagnostic challenge as there is no prototype presentation. We report a case of a child with Scrub typhus who developed a massive consolidation. Despite such an extensive consolidation, respiratory symptoms such as cough and breathlessness were inconspicuous thereby posing a diagnostic dilemma. Upon serological confirmation, doxycycline therapy was initiated with a rapid and complete resolution of the pneumonia, both clinically and radiologically. The case is being reported to highlight this unusual presentation of Scrub typhus in children.