Sodium valproate
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Proximal myopathy leading to waddling gait: case report A 13-year-old girl developed proximal myopathy leading to waddling gait during treatment with sodium valproate for absence seizures and mood disorder. The girl presented to hospital with an abnormal gait for the previous 6 months. Her mother noted that she was finding it progressively more difficult to walk. Prior to onset of these symptoms, she was able to walk without support, perform routine activities and to go to the school. Over the previous 6 months, she felt tired after being physically active, and she developed a dullaching pain in her thighs and hip that increased with prolonged activity, which was relieved by rest and unspecified analgesics. Her weakness progressively worsened to the extent that she was not able to walk to school, ride a bicycle or climb stairs. Her family members noted clumsiness in her gait, which was associated with her weakness. It was also noted that she had been receiving sodium valproate 200mg two times a day [route not stated] along with risperidone and trihexyphenidyl for the previous 3 years for absence seizures as well as a mood disorder. The girl was empirically treated with vitamin-D supplementation with no significant improvement in her gait. On physical examination, she was found to be moderately built. She was walking with a waddling gait and exhibited an exaggerated lumbar lordosis. The power in her hip abductors and deltoid was 4/5. Her sensations and all the deep tendon reflexes were found to be normal. The Trendelenburg test was bilaterally positive. She was able to squat and sit cross-legged but she had difficulty in standing up. Her routine X-ray examination was normal. She did not show signs of rickets or other hip disorders. Her serum alkaline phosphatase (ALP; 897 IU/L) and serum creatine kinase myocardial band (CK-MB; 35.9 IU/L) were elevated. Her serum vitamin-D3 level was normal. Vitamin-D supplementation was continued with the expectation of gradual improvement of her myopathy. At 1-week follow-up, her weakness did not improve. Her serum ALP level was found to be elevated. A possibility of proximal myopathy leading to waddling gait secondary to sodium valproate was therefore suspected [time to reaction onset not stated]. Sodium valproate was therefore discontinued. The serum sodium valproate levels were found to be within therapeutic levels. She was treated with carnitine supplementation. At 2-week follow-up, an improvement was seen. At 3-month follow-up, her gait was found to be improved, and her Trendelenburg test was found to be negative. Further, she reported that she was able to go to school, able to do cycling and run without feeling pain or exhaustion. Power in all the muscle groups was 5/5. Her serum ALP and CK-MB normalised. At that time, sodium valproate was changed to ethosuximide. Thereafter, no recurrence of her psychiatric or musculoskeletal symptoms was observed, and she recovered completely. Sharma A, et al. Waddling Gait: A complication of valproate therapy and a thought beyond vita
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