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Pancreatitis with normal serum amylase associated with sodium valproate: a case report
S Otusbo1, T Huruzono, H Kobae
1Department of Pediatrics, Faculty of Medicine, Kagoshima University, Japan.
Insights
Valproate medication can cause pancreatitis in children, even when standard amylase levels appear normal. Promptly test other pancreatic enzymes in children with neurological impairment if pancreatitis is suspected.
Area of Science:
- Pediatric Neurology
- Gastroenterology
- Clinical Pharmacology
Background:
- Valproate is a widely used antiepileptic drug.
- Postencephalitis syndrome can present with complex neurological deficits.
- Pancreatitis is a potential adverse effect of certain medications.
Observation:
- A 1-year-old infant with severe postencephalitis syndrome developed diarrhea and elevated pancreatic enzymes (elastase, lipase, trypsin) after 70 days of valproate therapy.
- Serum amylase levels remained within the normal range.
- Abdominal ultrasonography supported the diagnosis of pancreatitis.
Findings:
- The clinical presentation and laboratory findings suggested sodium valproate-induced pancreatitis.
- Elevated levels of elastase, lipase, and trypsin, despite normal amylase, indicated pancreatic injury.
- The diagnosis was challenging due to the patient's neurological impairment.
Implications:
- Valproate-induced pancreatitis can be subtle and easily missed in neurologically impaired children.
- Routine monitoring of serum amylase alone may be insufficient for diagnosing valproate-related pancreatitis.
- Investigating a broader range of pancreatic enzymes is crucial for early detection in at-risk pediatric populations.
Abstract:
The patient was a 1-year-old infant with severe postencephalitis syndrome. Diarrhea and elevation of the pancreatic enzymes, except for serum amylase (elastase 1 > 1, 5000 ng/dl (100-400); lipase, 885 IU/I/37 degrees C (10-48); trypsin, > 900 ng/ml (110-460)), were observed starting 70 days after starting valproate (dose, 70 mg/kg; serum level, 83.8 micrograms/ml). These findings as well as those obtained by abdominal ultrasonography suggested a diagnosis of pancreatitis, which was thought to be caused by sodium valproate. Important signs of valproate-induced pancreatitis may be easily overlooked in patients with neurological impairment, such as in ours. Because the blood half-life of amylase is short, not only amylase but some other pancreatic enzymes should be promptly investigated when valproate-related pancreatitis is clinically suspected in physically or mentally handicapped children.