BMJ case reports
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A 59-year-old man with a background of poststroke epilepsy, lung cancer, chronic obstructive pulmonary disease and hypertension, presented to the medical assessment unit with acute confusion and altered consciousness. Medications included sodium valproate, aspirin and antihypertensives. On examination he was confused, with his Glasgow Coma Scale fluctuating between 10 and 14. ⋯ Serum ammonia was elevated (75 µg/dL), consistent with a diagnosis of valproate-related hyperammonaemic encephalopathy. Sodium valproate was changed to a different antiepileptic drug and his confusion gradually resolved. Valproate-related hyperammonaemic encephalopathy is a treatable condition which should be considered as a diagnosis in anyone taking sodium valproate with new onset confusion, even in the presence of therapeutic sodium valproate levels and normal liver function tests.