A case of severe valproic acid intoxication with severe aspiration pneumonia treated by meropenem and supportive care

Abstract

A 55-year-old woman attempted suicide by overdosing on precipitation drugs (such as valproic acid (VPA) and phenobarbital). She was intubated in the emergency room due to a low level of consciousness, unstable respiratory and circulatory status, and evidence of pneumonia on a CT scan. Her serum VPA concentrations were high (＞150 μg/dL), indicating severe VPA intoxication. After hemodialysis therapy, repeated meropenem (MEPM) administration, and multidisciplinary treatment, her serum VPA concentrations rapidly declined and her general condition improved. She was successfully extubated on day 13 and transferred to another hospital on day 26 without any aftereffects.

VPA is commonly prescribed for conditions such as epilepsy, migraines, and depression. Large doses of VPA can cause fatal cerebral edema and death;therefore, reducing serum VPA concentrations as soon as possible is critical to the management of severe VPA intoxication. The liver metabolizes VPA, which then enters enterohepatic circulation. Acylpeptide hydrolase (APEH) removes the glucuronic acid group from VPA, thereby allowing its reabsorption in the gastrointestinal tract. Administration of MEPM can irreversibly inhibit the activity of APEH and prevent VPA reabsorption. Although it is counterintuitive, we suggest using MEPM along with VPA as a potential treatment for severe VPA intoxication.