Phenytoin
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Phenytoin toxicity with phenytoin-induced hyperammonaemic encephalopathy: case report A 55-year old man developed phenytoin toxicity with phenytoin-induced hyperammonaemic encephalopathy during treatment with phenytoin for chronic idiopathic generalised epilepsy. The man, who had chronic idiopathic generalised epilepsy, was admitted with complaints of acute alteration in behaviour, drowsiness and altered sleep pattern. He had been receiving oral phenytoin 400 mg/day. His medical history was significant for breakthrough seizures intermittently. Recently, he had suffered from a breakthrough seizure, for which he had been treated at a local clinic with IV phenytoin 600mg. Thereafter, he did not have recurrence of seizure; however, he became drowsy, irritable and was responding inappropriately, and was admitted (the current presentation). Upon examination, he was found to be responding to verbal commands, e.g. opening eyes; although, giving inappropriate answers to questions and was localising to painful stimuli (Glasgow coma scale score: 12). He was also clumsy in following motor commands and grossly ataxic when made to stand or walk. The pupillary and fundus examinations were normal, but bilateral gaze evoked nystagmus was noted. Brain MRI revealed bilateral basal ganglia hyperintensities on T1-weighted images with no postcontrast enhancement. There were other discrete hyperintensities on T2 and fluid attenuated inversion recovery (FLAIR) sequences. The 16-channel EEG revealed generalised polymorphic delta wave slowing, indicative of diffuse encephalopathy. Later, elevated levels of serum ammonia (336 µmol/L) and phenytoin (23.77 µg/mL) were detected. Finally, he was diagnosed with phenytoin toxicity with phenytoin-induced hyperammonaemic encephalopathy [duration of treatment to reactions onsets not stated]. The man’s therapy with phenytoin was therefore replaced with levetiracetam. Consequently, his condition improved and he became normal by the fourth day of admission. Author comment: "[P]henytoin causing hyperammonemic encephalopathy has not been reported earlier. Hence, we report one such case here." "He was diagnosed as a case of phenytoin toxicity with phenytoin-induced hyperammonemic encephalopathy." Pandey S, et al. Unexplained encephalopathy with phenytoin toxicity hyperammonemia, the underlying cause. Neurology India 66: 1829-1831, No. 6, Nov-Dec 2018. Available from: URL: http://doi.org/10.4103/0028-3886.246257 803431649 India
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Reactions 2 Nov 2019 No. 1777
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