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Rickets and multiple slipped epiphyses (first reports with carbamazepine and lamotrigine) in a child: case report An 11-year-old boy, who had severe nonambulatory spastic quadriplegia, developed rickets and multiple slipped epiphyses during treatment with carbamazepine, lamotrigine and valproate*. The boy, who had been receiving antiepileptic drugs since the age of 6 months and had been on triple antiepileptic drug scheme for the last 5 years, presented with a 2-month history of increasing discomfort during physiotherapy sessions; his most recent antiepileptic regime included carbamazepine, lamotrigine and valproate [dosages and duration of treatment to reaction onset not stated]. On clinical examination, he had painful swelling and reduced active range of movement of all major joints. He had flexion contractures of the knees and hips, associated with valgus deformity of both knees, which was more severe on the right side with lateral subluxation of the patella; he had extension contractures of the right ankle and wrist joints. X-rays revealed generalised dramatic increase in the growth plate height. He had slipped distal femoral, tibial and radial epiphyses on the right side, and slipped proximal femoral epiphyses bilaterally. On his left side, he had a mild posterior slippage of the distal tibial epiphysis; no signs of altered bone metabolism were observed in hip x-rays obtained at the age of 4 years. He had vitamin D-deficient rickets, borderline hypothyroidism and secondary hyperparathyroidism. The boy started receiving colecalciferol [vitamin D3], levothyroxine sodium and calcium supplements. Over the following months his biochemical markers normalised. His parents rejected the option of surgical treatment of the slipped epiphyses. His right knee was braced to improve the severe valgus and flexion knee deformity. However, his family did not comply fully with bracing instructions due to his discomfort and inability to rest and sleep with braces. Physiotherapy was continued. After two years of treatment, his biochemical markers had remained normalised and the growth plate of his ankle, knees and hip joints had closed. On the right side, he had residual mild dorsal angular deformity of the distal radius and severe valgus angular and mild rotational deformity of the right knee, with lateral patellar subluxation; the alignment of both distal tibial epiphyses had restored to normal. * specific salt not stated Petra M, et al. Anticonvulsant drug-induced rickets and multiple slipped epiphyses in a child treated non-operatively: a case report. Acta Orthopaedica Belgica 74: 801117541 413-417, No. 3, Jun 2008 - Greece

» Editorial comment: A search of AdisBase, Medline and Embase did not reveal any previous case reports of rickets or multiple slipped epiphyses associated with carbamazepine or lamotrigine. The WHO Adverse Drug Reactions database did not contain any reports of rickets [using MedDRA terminology] or epiphysiolysis associated with carbamazepine or lamotrigine.

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