[A severe, reversible encephalopathy after prolonged use of valproic acid]. / Ernstige, reversibele encefalopathie bij langdurig valproïnezuurgebruik.

Valproic acid is an effective mood stabilizer, registered for the treatment of bipolar disorder and epilepsy. Side effects of valproic acid are transient and generally well tolerated. A rare side effect is a valproic acid-induced encephalopathy. We saw a case of valproic acid-induced encephalopathy without hyperammonemia in a 71-year-old woman. She had used valproic acid as a mood stabilizer over the course of 16 years for a bipolar I disorder. The following clinical symptoms were observed: staring eye contact, somnolence, disorientation, hypotenacity, bradyfrenia, mutism and akathisia. Severe extrapyramidal symptoms were observed during neurological examination as well as hyperreflexia, a snoutreflex on both sides and a right-sided palmomental reflex. After cessation of the valproic acid, her symptoms disappeared completely. Based on this case report, we discuss the clinical aspects, pathophysiology, recognition and treatment of valproic acid-induced encephalopathy, both with and without hyperammonemia.

[The clinical diagnosis 'wound botulism' in an injecting drug addict]. / De klinische diagnose 'wondbotulisme' bij een drugsspuitster.

A 38-year-old subcutaneous injecting heroin addict had subacute blurred vision, dysarthria and dysphagia. The next day she could not swallow or speak and developed weakness of all limbs and respiratory failure. Electromyography showed abnormalities compatible with a presynaptic neuromuscular transmission deficit, which supported the diagnosis of botulism. The point of entry was probably a skin abscess due to injections. Treatment with antitoxin and antibiotics resulted in a favourable recovery. Wound botulism is caused by local production of toxin by Clostridium botulinum after wound infection. Although it is a rare variant of botulism, it is increasingly being reported in drug users who inject subcutaneously.