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We report four patients with hypothermia related to divalproex sodium (DVS) who improved dramatically on discontinuation of the drug, and one patient who had severe heat intolerance that improved with DVS.
Case reports.
Patient 1.
An 85-year-old right-handed man with a medical history of hypertension and multi-infarct dementia presented with right-side weakness and mental status changes after a fall. A left subdural hematoma with mass effect and a small posterior parietal intracerebral hematoma was detected on head CT. The patient did well after evacuation of the subdural hematoma. He was placed on phenytoin 100 mg thrice daily for seizure prophylaxis, which was then discontinued because of a generalized erythematous papular rash. He was subsequently started on DVS 250 mg thrice daily.
Neurologic examination revealed mild dementia. Laboratory studies were unremarkable except for mild elevation of blood urea nitrogen and sodium, which was corrected by IV fluids. Soon after starting DVS, the patient developed hypothermia and deterioration in mental status, with oral temperature falling to 36 °C. An extensive workup was performed to rule out infection. Blood culture and sensitivity times three, urine culture and sensitivity, urinalysis, chest radiograph, serum electrolytes, complete blood count, platelets, thyroid function tests, sedimentation rate, and liver function tests were within normal limits. Electrocardiogram showed normal sinus rhythm with left anterior fascicular block, nonspecific T-wave abnormality. A gallium scan was negative. Brain CT with contrast showed minimal subdural collection on the left, diffuse atrophy with small infarcts, and no evidence of abscess. Comparison with the previous scan showed definite improvement. The valproic acid level was 25 μg/mL. EEG did not show any seizure activity.
The patient showed rapid deterioration in his mental status with a rapid fall in his body temperature to 32.2 °C …
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