Monthly Case

Six months ago, a 10-year-old boy sufferer the first time from two generalized tonic clonic seizures that were preceded by an epigastric aura (feeling of warmth in the upper abdomen that slowly rises to the throat). Brain MRI was normal, thus in another hospital the correct diagnosis of cryptogenic partial epilepsy was made. Antiepileptic drug treatment was started with valproate, the 36-kg boy was put on a target dose of 1,500 mg daily.

With valproate, the boy did not have any further seizures, but his cognition and alertness declinced, his school performance impaired, eventually he appeared to be apathic.

In order to get a second opinion, the boy and his mother presented in our epilepsy outpatient clinic for children and adolscents. Valproate serum concentration was massively elevated at 148 mg/l (upper limit of reference range is at 100 mg/l). The patient was admitted to reduce valproate dose and to eventually switch the anticonvulsant to oxcarbazepine. Yet a couple of days after switching, the patient seemed to be more alert, his school performance can only be assessed in the course of the next weeks or months.

It is correct that after two unprovoked epileptic seizures the risk for next seizures is increased, and antiepileptic drug treatment is recommended. However, the boy suffers from partial epilepsy, and valproate is rather subordinated in that epilepsy syndrome. The actual problem is the rapid dose increase and the too high target dose of valproate in that boy. Serum concentration was not controlled for. Furthermore, epilepsy, anticonvulsant treatment and possibly associated side effects had not been discussed with and explained to the patient and his family. This now has been made good for by neuropediatricians and child neuropsychologists at our institution.

Cases of the months before