[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.

[Underexposed, potential lethal gastrointestinal adverse events associated with clozapine use]. / Onderbelichte, potentieel dodelijke gastro-intestinale bijwerkingen van clozapine.

Clozapine is an effective antipsychotic with antidopaminergic, anticholinergic and antiserotonergic effects. Due to potential adverse events, agranulocytosis being the most feared, patients using clozapine need to be closely monitored. A lesser known but equally common and potential lethal adverse effect is clozapine-induced gastrointestinal hypomotility (CIGH), which can cause a paralytic ileus, gut mucosal ischemia or aspiration pneumonia. We saw a male patient, aged 61 years, who used clozapine and suffered from CIGH, leading to frequent episodes of paralytic ileus requiring GE surgery. The case underlines the importance of timely recognition and treatment of clozapine-induced gastrointestinal hypomotility.